Infection Prevention and Control Best Practices for Personal Services Settings

Infection Prevention and Control Best Practices for
Personal Services Settings
Infection Prevention and Control Unit
Public Health Division
Ministry of Health and Long-Term Care
January 2009
Table of Contents
1.
Introduction............................................................................................................ 3
Purpose ................................................................................................................. 3
Applicability ........................................................................................................... 3
Statutory Basis ...................................................................................................... 3
Inspection Of Personal Services Settings By Board Of Health Staff..................... 4
Background ........................................................................................................... 4
2.
Glossary ................................................................................................................ 5
2.1
3.
General Guidelines For Equipment, Instruments And Supplies .......................... 13
3.1
4.
Physical Setting Requirements................................................................ 13
Operational Requirements For Personal Services Settings ................................ 15
4.1
5.
Routine Practices For Personal Service Settings.................................... 10
Sharps And Approved Sharps Containers............................................... 17
Cleaning, Disinfection And Sterilization............................................................... 18
5.1
Classification Of Equipment/Instruments................................................. 18
Table A: Classification For Methods Of Disinfection/Sterilization...................... 18
5.2
Cleaning .................................................................................................. 19
5.2.1
General Cleaning Requirements ............................................................. 19
5.2.2
Cleaning Of Equipment/Instruments........................................................ 19
5.3
General Cleaning Frequencies................................................................ 21
5.3.1
Cleaning Work Surfaces Contaminated With Blood/Body Fluids ............ 21
5.4
Disinfection .............................................................................................. 22
5.4.1
General Disinfection Principles................................................................ 22
5.5
Sterilization .............................................................................................. 23
5.5.1
General Sterilization Requirements......................................................... 24
A. Physical (Mechanical) Monitoring ...................................................... 26
B. Chemical Monitoring (Process Monitoring) ........................................ 26
C. Biological Monitoring.......................................................................... 27
6.
7.
8.
5.6
Disposal Of Equipment And Waste ......................................................... 29
5.7
Record Keeping....................................................................................... 29
Health And Personal Hygiene ............................................................................. 30
6.1
Occupational Health And Safety.............................................................. 30
6.1.1
General Hand Hygiene Principles ........................................................... 30
6.2
Health Of The Client ................................................................................ 31
Blood And Body Fluid Exposure Response Procedures ..................................... 32
7.1
Causes Of Exposure ............................................................................... 32
7.2
Procedure For Blood And Body Fluid Exposure...................................... 32
Additional Guidelines For Specific Personal Services......................................... 34
1
8.1
Manicures, Pedicures And Nail Treatments ............................................ 34
8.1.1
Nail Fungus, Nail “Mould” ........................................................................ 34
8.1.2
Additional Requirements To The General Guidelines ............................. 34
8.2
Electrolysis And Laser Hair Removal ...................................................... 35
8.2.1
Additional Requirements To The General Guidelines ............................. 35
8.3
Tattooing And Micropigmentation............................................................ 36
8.3.1
Additional Requirements To The General Guidelines Before Tattooing
And Micropigmentation............................................................................ 36
8.3.2
Additional Requirements To The General Guidelines After Tattooing And
Micro-Pigmentation.................................................................................. 37
8.4
Body Piercing .......................................................................................... 38
8.4.1
Additional Requirements To The General Guidelines ............................. 38
8.5
Ear Lobe Piercing .................................................................................... 39
8.5.1
Additional Requirements To The General Guidelines ............................. 39
8.6
Acupuncture ............................................................................................ 40
8.6.1
Additional Requirements To The General Guidelines ............................. 41
8.7
Hairdressing/Barbering............................................................................ 42
References
................................................................................................................. 44
Table 1 :
Steps To Clean Instruments .................................................................... 46
Table 2 :
Disinfection Chart .................................................................................... 47
Figure 1:
Cleaning, Disinfection And Sterilization Flowchart .................................. 48
Table 3:
Steps To Sterilization Of Instruments ...................................................... 49
Table 4:
Detailed Infection Prevention And Control Procedures For Electrolysis
................................................................................................................. 50
Table 5:
Detailed Infection Prevention And Control Procedures For Body Piercing
................................................................................................................. 55
Table 6:
Detailed Infection Prevention And Control Procedures For Tattooing And
Micropigmentation ................................................................................... 60
Table 7:
Detailed Infection Prevention And Control Procedures For Ear Lobe
Piercing.................................................................................................... 65
Table 8:
Preparing Household Bleach As A Disinfectant ...................................... 68
Table 9:
Times And Temperatures Required For Dry Heat Sterilization ............... 69
Appendices ................................................................................................................. 70
Appendix 1:
Methyl Methacrylate (MMA)..................................................................... 71
Appendix 2:
Ear Candling............................................................................................ 72
Acknowledgements ...................................................................................................... 73
2
Infection Prevention and Control Best Practices in
Personal Services Settings
1.
INTRODUCTION
Purpose
This document has been developed for public health inspectors to educate
personal service workers (PSWs) to reduce the risk of transmission of blood
borne and other types of infection for both clients and PSWs during the delivery
of personal services. Percutaneous exposure (through penetration of skin) or
mucous membrane exposure to blood or body fluids can lead to infection with
blood-borne pathogens including Hepatitis B (HBV), Hepatitis C (HCV), Human
Immunodeficiency Virus (HIV), other human retroviruses, bacteria and other
pathogens of concern, such as mycobacteria. For this reason, infection
prevention and control precautions must be taken in every personal service
setting. It is the responsibility of the owner/operator to ensure all PSWs are
educated in regards to infection control requirements specified in this protocol;
both the client and the operator may be at risk of infection. It is important to
recognize that blood and body fluids do not have to be visible on
instruments or other surfaces for an infection to be transmitted.
Applicability
This best practice document applies to any facility, service or person offering
services where there is a risk of exposure to blood, such as, but not limited to:
hairdressing and barber shops, tattoo and body piercing studios, electrolysis,
acupuncture and various aesthetic services. The following guidelines comprise
general recommendations for all personal service settings and equipment.
Requirements specific to each area of practice are presented in summarized
formats following the general guidelines.
Statutory Basis
This document is to be used in conjunction with the Infection Prevention and
Control in Personal Services Settings Protocol, 2008. This protocol is named in
requirement No. 10 under the Infectious Diseases Prevention and Control
Standard of the Ontario Public Health Standards, 2008, published by the Minister
of Health and Long-Term Care as authorized by Section 7 of the Health
Protection and Promotion Act (HPPA), Revised Statutes of Ontario, 1990.
Note: The Regulated Health Professions Act (RHPA) provides that no person
shall perform a controlled act (e.g. a surgical procedure) in the course of
providing health care services to an individual unless:
(a)
the person is a member authorized by a health profession Act to
perform the controlled act; or
3
(b)
the performance of the controlled act has been delegated to the
person by a member of a regulated health profession.
Any regulated health professional under the RHPA does not require their
practice to undergo routine inspections by health unit staff as delineated
below.
Inspection of Personal Services Settings by Board of Health Staff
Routine inspections are required for all personal services settings at least once a
year by the Medical Officer of Health for each health unit or their designate.
These guidelines also apply to “special events” such as trade shows,
conventions, fairs or exhibitions.
Personal Services Settings that serve food must be in compliance with the HPPA
in regards to Food Premises.
Background
The use of personal service settings has become a way of life for many
individuals.
The range of services offered varies from hair care to invasive procedures such
as tattooing and piercing. A 2002 study conducted with university
undergraduates found that tattoos were present in 22% of men and 26% of
women with an average of one to three sites per person. Piercing was found to
be more common with 42% of men and 60% of women reporting that they were
pierced. The popularity of personal services has also highlighted the risk of
infection in many of these services. Mycobacterial infections related to
inadequate cleaning and disinfection of footbaths have been reported. However
the lack of formal surveillance of infections related to personal service settings
makes it difficult to provide accurate information on the actual risk of these
procedures.
Lack of infection prevention and control practice in personal service settings, can
affect the health of the client as well as present a risk to the operator. Infections
may be spread during procedures even when skin penetration does not occur.
Staff who are knowledgeable and consistently practice infection prevention and
control will significantly reduce the risk of infections being transmitted within the
personal service setting. Public health staff must be knowledgeable resources for
personal service staff and assist them in providing a safe environment.
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2.
GLOSSARY
The following definitions apply throughout this protocol:
Approved sharps container A dedicated, puncture resistant, tamper-resistant,
leak-proof container, which is impenetrable by
sharps. It should have a tight-fitting lid and bear a
clearly identifiable biological hazard label.
Acquired
Immunodeficiency
Syndrome (AIDS)
A broad spectrum of disease caused by HIV
ranging from asymptomatic infection to advanced
clinical disease, which is characterized by
acquired immunosuppressant.
Acupuncture
The remedial use of long thin needles that are
inserted into the skin on specific “energy points”
of the body. After shallow insertion, they may be
gently rotated as part of the process.
Antiseptic
A chemical agent that destroys micro-organisms
on human skin or mucosa
Applicator
A device for applying a substance. Includes a
single-use, disposable spatula or a similar device.
Aseptic technique
The absence of pathogenic (disease producing)
organisms.
Bacteria
A single cell micro-organism that may cause
disease in plants, animals or humans.
Blood-borne infections
Infections (e.g., HIV, HBV, HCV infections)
spread through contaminated blood or other body
fluids, including semen, vaginal secretions or
saliva.
Body fluid
Human body fluids include such things as blood,
semen, saliva, sputum and body tissue. Persons
who come into contact with human body fluids
may be exposed to a number of potential health
risks. Of particular concern are HBV, HCV and
HIV.
5
Equipment/devices that enter sterile tissues,
Classification of Devices
Critical equipment/devices: including the vascular system (e.g. needles, etc.).
Critical equipment/devices present a high risk of
infection if the equipment/device is contaminated
with any microorganisms, including bacterial
spores. Reprocessing critical equipment/devices
involves meticulous cleaning followed by
sterilization.
Noncritical
equipment/device:
Equipment/device that either touches only intact
skin (but not mucous membranes) or does not
directly touch the client. Reprocessing of
noncritical equipment/devices involves cleaning
and may also require low-level disinfection (e.g.
cupping equipment, etc.).
Semicritical
equipment/device:
Equipment/device that comes in contact with
nonintact skin or mucous membranes but
ordinarily does not penetrate them (e.g. tweezers
used to remove ingrown hairs, etc.).
Reprocessing semicritical equipment/devices
involves meticulous cleaning followed by, at a
minimum, intermediate level disinfection.
Cleaning
The physical removal of organic matter or debris
from objects, usually done using water, detergent
and friction. This process removes
microorganisms primarily by mechanical action
but does not destroy those remaining on the
object.
Contamination
The presence of an infectious agent on a surface,
clothes, instruments, dressings or other
inanimate articles or substances including water.
Controlled Act
Under the RHPA (refer to glossary) a controlled
act includes but is not limited to: performing a
procedure on tissue below the dermis or below
the surface of a mucous membrane and applying
or ordering the application of a form of energy on
any part of the body. For further information refer
to: http://www.elaws.gov.on.ca/html/statutes/english/elaws_statut
es_91r18_e.htm#BK23
Cross-contamination
The transfer of an infectious agent from a
6
contaminated source to a non-contaminated
source.
Disinfectant
A substance used on inanimate objects that
destroys bacteria, fungi, viruses and some
bacterial spores depending on the level of the
disinfectant and the contact time used.
Disinfection
A process that kills or destroys most diseaseproducing micro-organisms, with the exception of
high numbers of bacterial spores. There are
different levels of disinfection.
High-level disinfection
The level of disinfection required when
processing some semicritical equipment/devices.
High level disinfection processes destroy
vegetative bacteria, mycobacteria, fungi and
enveloped (lipid) and non-enveloped (non-lipid)
viruses, but not necessarily bacterial spores.
Equipment/devices must be thoroughly cleaned
prior to high level disinfection
Intermediate-level
disinfection
Level of disinfection required when processing
some semicritical equipment/devices.
Intermediate-level disinfection kills mycobacteria,
most viruses, and bacteria. Equipment/devices
must be thoroughly cleaned prior to intermediate
level disinfection.
Low-level disinfection
Level of disinfection required when processing
noncritical equipment/devices or some
environmental surfaces. Low-level disinfectants
kill most vegetative bacteria and some fungi as
well as enveloped (lipid) viruses. Low-level
disinfectants do not kill mycobacteria or bacterial
spores. Equipment/devices must be thoroughly
cleaned prior to low-level disinfection.
Electrolysis
The removal of hair from the body by inserting a
solid needle into the hair follicle where the hair
shaft emerges. An electric current is passed
through the needle to destroy the hair follicle and
the hair is removed with tweezers.
Hand Hygiene
A process to remove or destroy micro-organisms
on hands. Can be done with soap and running
7
water or an alcohol-based waterless agent,
provided hands are not visibly soiled.
Hepatitis B virus (HBV)
An infection of the liver caused by the hepatitis B
virus.
Hepatitis C virus (HCV)
An infection of the liver caused by the hepatitis C
virus.
Human immunodeficiency
virus (HIV)
The virus that causes AIDS.
Infection
Entry into and multiplication of infectious
microorganisms within the body.
Infection prevention and
control
The process of minimizing the risks of spreading
infection.
Infectious disease agent
Microorganisms such as viruses, bacteria, or
fungi that are capable of producing disease.
(Also referred to as “pathogens”).
Infectious waste
All waste which could potentially be contaminated
with disease-causing microorganisms, (i.e.
bacteria, and/or viruses).
Instrument
An item or piece of equipment used during the
process of carrying out personal services. This
also applies to implements.
Invasive instrument
Any instrument designed to penetrate the skin.
Invasive procedure
Any procedure intended to break the skin (e.g.
tattooing, micro pigmentation, piercing,
electrolysis, acupuncture etc.).
Micro pigmentation
The permanent imprinting of cosmetic shading
also known as “permanent makeup” or “cosmetic
tattooing” using different coloured inks or
pigments. The process is similar to tattooing and
may be done using either a traditional tattoo
machine or an implanter.
Mucous membrane
Moist tissue that lines some organs and body
cavities (such as nose, mouth, lungs) and
secretes mucous (a thick fluid).
8
Mycobacterium
A bacteria with over 50 species, of which at least
20 have been reported to cause disease in
humans. This bacteria has been isolated from
various sources including water, birds, animals
and soil.
Personal service settings
Settings in which aesthetic services such as body
piercing, tattooing, hairdressing salons (etc.) are
delivered.
Personal service worker
(PSW)
A person who operates or practices in a business
offering personal services.
Piercing
The perforation or piercing of a client’s body and
the attachment or insertion of jewelry. It can be
done with a piercing needle, a piercing gun, a
trocar and cannula, a dermal punch, or a scalpel.
Puncture
Accidental or intentional penetration (break)
through the skin or other body tissue.
Regulated Health
Professions Act (RHPA)
The Act governing certain self-regulated groups
of healthcare professionals. The PSSP does not
cover services, such as mole or ingrown nail
removals, provided by professionals regulated
under this Act. This would include services
provided by physicians, nurses, physiotherapists,
registered massage therapists, chiropractors, etc.
Routine Practices
The Health Canada/Public Health Agency of
Canada term to describe the system of infection
prevention and control practices recommended in
Canada to prevent and control transmission of
microorganisms. In the United States these are
called Standard Precautions. These practices
describe prevention and control strategies to be
used with all clients during all care.
Sharps
Any item that may penetrate the skin (e.g.
needles, blades, lancets, razors, scalpel, etc.).
Single-use (disposable)
items
Any instruments or items that are designed to be
used once and then discarded as they cannot be
adequately cleaned and disinfected or sterilized.
9
Spores
A form assumed by some bacteria that is
resistant to heat, drying and chemicals. Under the
right environmental conditions, the spore may
revert to the actively multiplying form of the
disease.
Sterilization
The level of reprocessing required when
processing critical equipment/devices.
Sterilization results in the destruction of all forms
of microbial life including bacteria, viruses, spores
and fungi. Equipment/devices must be cleaned
thoroughly before effective sterilization can take
place.
Styptic pencil
A medicated stick, often made of alum, that may
be applied to a wound or cut to stop bleeding.
The stick must never come into contact with the
wound or open cut. Coagulant products must be
applied so that the applicator is either disposable
or the reusable applicator is not contaminated.
Tattooing
The permanent or indelible imprinting of a
decorative design into the skin. Tattoo needles
on the end of a reciprocating needle bar are used
to puncture the skin or mucosa and introduce
different coloured inks or pigments.
Virus
A micro-organism that can only replicate within
living host cell.
2.1
ROUTINE PRACTICES FOR PERSONAL SERVICE SETTINGS
Guidelines for the control of infections are needed to assist in developing
policies and procedures to ensure an optimal level of care is provided.
These guidelines should be seen as directing principles and indications or
outlines of the expected practice.
The goal of infection prevention and control is to provide service in a
manner that reduces the risk of transmission of microorganisms to the
client and the personal service worker. Service should be provided in a
manner that prevents disease transmission. Infection prevention practices
must be tailored to the services being provided.
Routine Practices describe prevention and control strategies to be used
with all clients during all service delivery and include:
10
•
Hand Hygiene
o
Hand hygiene should be performed
 Between clients
 Before performing invasive procedures
 After contact with blood, body fluids, secretions and
excretions
 After contact with items known or considered likely to be
contaminated with blood, body fluids, secretions, or
excretions
 Immediately prior to and after removing gloves
 Between procedures on the same client in which soiling
of hands is likely, to avoid cross-contamination of body
sites
 When hands are visibly soiled
o
o
o
o
•
Plain dispensable soap may be used for routine hand
washing
When hands are visibly soiled, hands must be washed with
soap and water
Alcohol-based hand rubs are an acceptable method of hand
hygiene especially when access to hand washing facilities is
limited.
Adequate facilities for hand washing in PSSs need to be
ensured.
Gloves
o
Gloves are not required for routine procedures in which
contact is limited to a client’s intact skin
o
Gloves are not a substitute for hand hygiene
o
Clean, non-sterile gloves should be worn
 For contact with blood, body fluids, secretions and
excretions, mucous membranes, or non-intact skin
 When handling items visibly soiled with blood, body
fluids, secretions and excretions
 When the PSW has non-intact skin on the hands
o
Gloves should be changed between procedures with the
same clients and between clients
o
Gloves should be removed immediately after completion of
the procedure, at the point of use and before touching clean
environmental surfaces
o
Hand hygiene should be performed immediately after
removing gloves
o
Single-use disposable gloves should not be reused or
washed.
11
•
Face Protection
o
Face protection should be worn to protect mucous
membranes of the eyes, nose and mouth during procedures
likely to generate splashes or sprays of blood, body fluids,
secretions, or excretions.
•
Gowns
o
Gowns should be used to protect uncovered skin and
prevent soiling of clothing during activities likely to generate
splashes or sprays of blood, body fluids, secretions or
excretions.
•
Equipment and Environment
o
Articles that touch the client’s intact skin should be clean.
o
Equipment touching mucous membranes or non-intact skin,
should be appropriately disinfected between clients
o
Chairs, cabinets, counters and charts should be cleaned on
a regular basis.
o
Soiled client care equipment should be handled in a manner
that prevents exposure of skin and mucous membranes and
contamination of clothing and the environment.
o
Used needles and other sharp instruments should be
handled with care to avoid injuries during disposal. Used
sharp items should be disposed of in an approved punctureresistant container located in the area where the sharps item
are used.
o
All equipment that is being used by more than one client
must be cleaned or cleaned and disinfected or sterilized as
appropriate between client according to recommendations.
12
3.
GENERAL GUIDELINES FOR EQUIPMENT, INSTRUMENTS AND
SUPPLIES
3.1 Physical Setting Requirements
The work site must be appropriate to the personal service activity.
Contact surface(s) (counters, tables, trays, lamps, magnifiers, etc.)
must have a smooth and non-absorbent finish.
The work area(s) must be well lit to facilitate cleaning and prevention of
injuries.
All personal services settings must be equipped with a sink(s) for
hand washing.
The hand washing sink(s) must be:
conveniently located near the work area(s) but at least one metre away
from where sterile or clean supplies are located.
accessible for use while personal services procedures are being
performed (i.e. sink is free of cleaning equipment) and
continuously supplied with potable hot and cold running water,
dispensable liquid soap from a single-use disposable container and
single-use (cloth or paper) hand towels in a dispenser. If the soap
container is refilled, it must first be cleaned, disinfected with low-level
disinfectant, rinsed and allowed to thoroughly air dry.
Note: A washroom hand sink(s) within the PSS premises may be used
for hand washing as long as it satisfies the requirements in section
3.1 (v).
Hand washing sinks used by more than one premise are not
acceptable (i.e. hand washing sinks in a public washroom within a
mall).
All personal services settings must be equipped with a sink(s) for
cleaning of equipment/instruments.
The cleaning sink(s) must be:
conveniently located near the work area(s)
continuously supplied with potable hot and cold running water and
of adequate size to accommodate the largest instrument/item of
equipment to be cleaned.
13
If there is only one sink available within the PSS premises, the same
sink may be used for both hand washing and cleaning of
equipment/instruments providing that it satisfies the requirements of
3.1 (v) and (viii). The PSS water supply should be tested in accordance
with local water regulations, unless the water is from a municipallycontrolled water source (e.g. tap water in a city or town).
Note: In the event that a plumbing system cannot be installed in an existing
personal service setting (e.g. premises is located in an older building), the
PSS must seek approval from their local health department in order to use
a portable sink. Such sinks must be inspected and approved by the health
unit to ensure a health hazard does not exist.
14
4.
OPERATIONAL REQUIREMENTS FOR PERSONAL SERVICES
SETTINGS
i.
All equipment/instruments or items used must be of durable
construction, maintained in good repair, and be in a clean and
sanitary condition. All cracked chipped, rusted or otherwise damaged
instruments not suitable for use shall not be used and shall be
discarded.
ii.
All reusable equipment/instruments or items and work contact
surfaces (e.g. chairs, tables, equipment trays, etc.) used in the
delivery of personal service procedures must be thoroughly cleaned
and then disinfected or sterilized after each use in accordance with
Tables 1 to 3 and following the requirements detailed in the cleaning,
disinfection and/or sterilization sections that follow. Working surfaces,
where invasive procedures are performed, must be cleaned and
disinfected with a low-level disinfectant between clients.
iii.
All equipment/instruments or items that cannot be easily or
thoroughly cleaned, disinfected or sterilized between each use shall
be considered as single-use, disposable items. If an item cannot be
cleaned, there is no way to adequately sterilize or disinfect it.
iv.
All single-use disposable equipment/instruments or items shall be
appropriately discarded immediately after use. Single-use covers
such as table covers, paper towels or dental bibs are single-use
items and must be disposed after each client. Reusable towels are to
be laundered after each use. All items are to be stored in a manner
that prevents contamination.
v.
Elastic bands used on equipment/instruments must be discarded
after each client.
vi.
Re-usable equipment/instruments, items and work contact surfaces
that cannot be easily or adequately cleaned, disinfected or sterilized
between each use (i.e. tattoo or pigmentation machines, electrolysis
control panels, pigment or spray bottles used during service, etc.)
shall be covered with single-use, disposable covers (e.g. plastic wrap
or plastic bags) and the cover shall be discarded after each use.
vii.
Any equipment/instruments or item that is touched or handled during
a procedure (even if not used during the procedure) shall be
considered contaminated. If the item is single-use disposable, the
item shall be discarded. If the item is re-usable, it must be cleaned
and then disinfected or sterilized before the next use.
15
viii.
During any procedure, routine infection prevention and control
practices must be followed to prevent contamination of disinfected or
sterilized equipment through contact with work surfaces, clothing or
hands (refer to 2.1).
ix.
Sterile instruments (e.g. needles, piercing jewelry, forceps, or other
items) that become contaminated (i.e. that touch a person, or that
come into contact with any other surface or item prior to use) shall
not be used and shall be immediately replaced with another sterile
instrument.
x.
All products (i.e. wax, pigment, creams, lotion, or cotton balls) must
be dispensed in a manner that does not contaminate the remaining
portion.
xi.
Any styptic product used must be single-use and discarded after
each client. Styptic pencils cannot be used to stop bleeding on
clients. Powder or liquid form is acceptable provided that if direct
contact with the skin is required, that it be applied by use of a
disposable applicator.
xii.
Prior to a PSW performing any invasive procedure, the client site
shall be cleansed with a skin antiseptic (e.g. iodine, 70% isopropyl
alcohol, 2% chlorhexidine gluconate, 0.5% chlorhexidine gluconate
with 70% alcohol, etc.)
xiii.
Whenever a surface anaesthetic is used on a client site, it shall be
applied using a clean, single-use, disposable swab. The site must
first be cleaned with an approved skin antiseptic, then marked with a
(iodine) felt tip/marking pen prior to the procedure. After one minute,
once the pen mark has dried, the site is to be cleaned again with the
approved skin antiseptic just prior to the procedure. (Refer to 6.2 ii)
Injectable anesthetics are not to be used.
xiv.
Clean linen must be stored in a manner that protects it from
contamination. All linen must be laundered or discarded after each
client use.
xv.
It is recommended that the personal service settings’ first aid/safety
kit be equipped with a magnet for retrieval of broken or dropped
needles, if needles are used in the premise.
xvi.
Personal items belonging to personal service worker/s (e.g. food,
medication, aesthetic items) shall not be stored with client supplies.
16
4.1
Sharps and Approved Sharps Containers
i.
All sharps that are intended for use to penetrate the skin and/or
mucous membranes (e.g. needles, scalpel, etc.) must be provided
as sterile, single-use disposable items. Never re-use needles or
scalpels.
ii.
Needles shall not be tested for sharpness or defects (e.g. damaged
or blunt points) on the client or PSWs skin before use but shall be
visually inspected.
iii.
Needles that require modification or attachment to other items (e.g.
tattoo needles) shall be cleaned in an ultrasonic cleaner, packaged
and then sterilized prior to being used.
iv.
Used disposable, sharps shall be discarded into an approved
sharps container immediately after each single use. Full (3/4 of
capacity) sharps containers must be securely closed and shall not
be discarded with the regular garbage. They must be discarded in
accordance with biomedical waste regulations.
v.
Needles and other sharps shall not be saved for future use on any
person (even on the same client).
vi.
Needles/needle bars and other sharps (e.g. lancets, razor blades,
scalpel, etc.) shall not be taken apart, bent, recapped re-covered or
otherwise manipulated after use prior to disposal.
vii.
Approved sharps containers are required for the safe disposal of
used, disposable sharps (e.g. razor blades, needles, lancets,
scalpel, etc.).
17
5.
CLEANING, DISINFECTION AND STERILIZATION
5.1 Classification of Equipment/Instruments
The rationale for cleaning and disinfecting or sterilizing equipment and
instruments is based on the intended use of the item. For the purposes
of this document, equipment/instruments used in PSSs can be divided
into three general categories: critical, semi-critical and non-critical.
Table A gives some general guidance regarding cleaning, disinfection
and sterilization requirements for equipment and instruments based on
their classification.
Note: The intended use of an item guides requirements for its appropriate
cleaning and disinfection or sterilization, rather than the name of the item.
Table A:
Classification for Methods of Disinfection/Sterilization
Adapted from Infection Prevention and Control Practices for Personal Services:
Tattooing, Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
Classification
Critical Items
Definition
•
•
Instruments that
penetrate the skin (used
for an invasive
procedure) and
Instruments that hold
sterile items. In some
cases, high-level
disinfection may be
acceptable.
Semi-critical
•
Instruments that come in
contact with non intact
skin or mucous
membranes, but are not
intended to penetrate
them.
Non-critical
•
Instruments that come in
contact with intact skin.
Method to be Used
•
Thorough cleaning followed
by sterilization is required.
Refer to Table 3
Note: Some equipment must be
supplied sterile and discarded
following use as it cannot be
adequately cleaned or reused.
•
Thorough cleaning followed
by intermediate or high-level
disinfection is required.
Refer to Table 1 and Table 2 for
more detailed information.
•
Thorough cleaning followed
by low-level disinfection is
required.
Refer to Table 1 and Table 2 for
more detailed information.
18
5.2
Cleaning
If an item or surface is not clean it cannot be disinfected or sterilized.
Cleaning is a process that removes visible dirt (organic matter) and some
microorganisms from work surfaces, instruments and equipment, allowing
the disinfection or sterilization processes to work effectively.
Cleaning must always occur as a first step before disinfection or
sterilization. Manual cleaning involves the use of a detergent and water
solution and scrubbing (the use of friction) to remove soil. Mechanical
cleaning of equipment/instruments involves the use of an ultrasonic
cleaner and an appropriate cleaning solution.
Detergents shall be rinsed off instrument/equipment surfaces prior to
disinfection to prevent neutralization of the disinfectant. Refer to Table 2
(in regards to disinfection).
5.2.1 General Cleaning Requirements
i.
Prior to disinfection or sterilization, all equipment/instruments and
environmental surfaces must be thoroughly cleaned either:
a) manually using lukewarm water, an enzymatic cleaner/detergent
and a scrub brush
b) or in conjunction with manual cleaning, mechanically, using an
ultrasonic cleaner and an appropriate cleaning solution.
5.2.2 Cleaning of Equipment/Instruments
i.
ii.
PSWs shall always wear appropriate personal protective equipment
(PPE) according to Routine Practices when cleaning and
disinfecting contaminated equipment/instruments and other
surfaces in an attempt to prevent any potential for penetration of
the skin or splashing of mucous membranes (such as eyes) during
the cleaning and disinfection process.
Routine Practices include the use of:
a) a pair of thick rubber (utility) gloves to protect hands and lower
arms
If there is a risk of splashing, the following PPE should also be used in addition to
utility gloves:
b) non-absorbent (i.e. plastic or vinyl) aprons or gowns to protect work
clothing and the upper body
c) safety glasses or goggles to protect the eyes. Prescriptive eyewear
does not provide appropriate protection.
19
iii.
The PSW shall scrub the equipment/instruments below the water
surface to prevent splashing into the eyes or onto clothing.
iv.
Dirty equipment/instruments shall be kept separate from clean
equipment/instruments at all times to prevent cross contamination.
v.
Whenever possible, dirty/contaminated equipment/instruments shall
be cleaned immediately after use on each client in order to prevent
drying of debris or blood proteins on their surfaces.
vi.
When it is not possible to clean dirty/contaminated reusable
equipment/instruments immediately after each use, they shall be
placed to soak in clean, lukewarm water (with or without detergent)
to prevent drying of debris/blood proteins onto their surfaces. The
sink designated for cleaning may generally be used for this
purpose. See section (viii and ix) below for exception.
vii.
Other materials used for cleaning equipment/instruments (e.g.
rubber utility gloves, scrub brushes, etc.), must be cleaned and lowlevel disinfected after each cleaning session. When not in use, they
must be stored dry.
Exception to Paragraph 5.2.2 (vi) – Use of Designated Cleaning Sink for
Cleaning of Equipment/Instruments
viii.
If only one sink is available within the premises for both hand
washing and cleaning of instruments/equipment, precautions shall
be in place to ensure that this single sink is always available for
hand washing while procedures are being performed. In this
instance, a puncture-resistant container with a tight-fitting lid,
containing water or water and detergent, must be used to store
dirty/contaminated instruments until they are ready to be cleaned.
ix.
The designated cleaning sink and/or dirty instruments container (if
required) must be of adequate size to accommodate the largest
instrument/equipment to be cleaned. If a container is used, it must
be appropriately labelled “dirty instruments” and must only used for
this purpose. Equipment used for soaking (i.e. sink, containers)
must be cleaned and then disinfected after each use.
x.
If an ultrasonic cleaner is used for cleaning instruments, the device
shall:
a) be operated with the lid on to prevent any microorganisms present
in the cleaning solution from splashing or becoming airborne and
potentially contaminating surfaces
20
b) be operated and maintained according to the manufacturer’s
instructions
c) be cleaned and disinfected at the end of each day’s use in
accordance with manufacturer’s directions
d) be stored dry after the unit is cleaned and disinfected and
e) be operated such that the cleaning solution is changed daily (when
in use) and more often when the cleaning solution is visibly dirty.
Note: Ultrasonic cleaners do not disinfect or sterilize equipment/
instruments. However, when properly used, they do provide a very safe and
effective means of cleaning instruments prior to disinfection or
sterilization.
5.3
General Cleaning Frequencies
i.
Work contact surfaces, such as manicure/pedicure tables,
tattooing/piercing equipment trays, magnifying lamps, clip cords,
electrolysis units, etc. must be either:
a) cleaned between each client using a detergent and water solution
and friction and then disinfected or sterilized or
b) covered with a single-use cover that must be disposed of after
each client.
Note: If a single-use disposable covering is used, work contact surfaces
must still be cleaned (at a minimum) at the end of each day and as often as
necessary when they become visibly soiled.
ii.
Other PSW or client contact surfaces within the premises (i.e.
counters, client chairs, washroom surfaces, etc.) shall be cleaned
(at a minimum) at the end of each day or more frequently if
necessary when they become visibly soiled.
iii.
Floors, walls, cupboards, shelving and other structural surfaces that
are not routinely contacted during the course of service delivery
must be cleaned when visibly soiled and daily (at a minimum) when
they are not visibly soiled.
Note: If, at any time, any surface within the premises become contaminated
with blood or body fluids, these surfaces should be immediately cleaned
and then disinfected as detailed below.
5.3.1 Cleaning Work Surfaces Contaminated with Blood/Body Fluids
i.
Single-use gloves must be worn during cleaning and disinfection
processes.
21
5.4
ii.
Surfaces that have become contaminated with blood or other body
fluids must be wiped up as soon as possible while wearing gloves
using a disposable cloth or paper towel and then immediately clean
the surface. The surface must then be disinfected with a high-level
disinfectant, ensuring sufficient contact time. Refer to Table 1 and
2.
iii.
Cloths, gauze or paper towels used for wiping up blood or other
body fluids must be discarded in a plastic bag to be placed in
regular garbage (refer to section 5.6).
Disinfection
Disinfectants destroy bacteria, fungi, viruses and some bacterial spores
depending on the level of the disinfectant and the contact time used.
Disinfectants are categorized as high-level, intermediate-level and low-level;
please refer to the disinfectant chart Table 2.
The Ministry of Health and Long-Term Care recommends that product labels of
disinfectants have a drug identification number (DIN) (with the exception of
hypochlorite). The presence of a DIN indicates that, upon a Health Canada
review, it has been established to be safe and effective for its intended use. The
designation germicidal, virucidal or tuberculocidal is not sufficient.
As well, distributors of products should provide Material Safety Data Sheets
(MSDS), which list ingredients and first aid measures, according to Workplace
Hazard Information and Material Information Safety (WHMIS) guidelines.
5.4.1 General Disinfection Principles
i. In order for a disinfectant to work properly, instruments and
equipment must first be thoroughly dismantled (if appropriate) and
cleaned.
ii. Follow manufacturer’s instructions for product dilution, use, reuse
and contact time in line with recommendations from Health
Canada.
iii. Do not store equipment or instruments in disinfectants for longer
than the required contact time.
iv. All solutions must be prepared, maintained (e.g. dilution, ventilation
and storage) and disposed of according to the manufacturer's
instructions.
22
v. All solutions used for high-level disinfection must be tested daily at
a minimum when such test strips exist to ensure that the
concentration is within acceptable limits.
5.5
Sterilization
Operators should consult with their local public health unit when
considering the purchase of a sterilizer.
Sterilization is a process of destroying all microorganisms including
bacterial spores. Sterilization is accomplished by using an autoclave,
chemical autoclave, or a dry heat sterilizer, based on time and/or
temperature of exposure.
Pressure cookers, glass-bead sterilizers, microwaves, ultraviolet
light, immersion in boiling water and domestic ovens are NOT
approved methods of disinfecting or sterilizing equipment.
Autoclave sterilization is dependent on temperature, pressure, duration of
exposure, packaging of the instruments and size of the load. The unit
must achieve a sufficiently high temperature for a required length of time.
It is important that the sterilizing chamber be loaded correctly and not
overloaded. Autoclaves use pressure in combination with heat and time to
achieve sterilization. All autoclaves must meet with Canadian Standards
Association specifications for use in health care or allied health facilities.
As per Canadian Standards Association Guidelines, a drying cycle is
required for all sterilization cycles for wrapped or packaged goods. The
autoclave should be equipped with a print-out that provides details of the
mechanical parameters reached during each cycle
Dry heat sterilization is dependent on the sterilizer unit achieving a
sufficiently high temperature for a prescribed duration of exposure.
Functioning thermometers must be in place to verify temperatures;
sterilization time does not start until the appropriate temperature is
attained. Ensure instrument packaging can withstand the temperature
needed to achieve sterilization. Refer to Table 9 for times and
temperatures for dry heat sterilization.
Chemical autoclaves utilize a disinfectant in combination with heat,
pressure and time.
Manufacturer’s instructions regarding packaging, loading, temperature,
pressure and time requirements must be followed. The sterilizer unit
manufacturer’s instruction manual shall be kept accessible for reference
within the premises at all times.
23
Some chemical (cold) sterilants (e.g. glutaraldehyde) are not
recommended for personal service settings because of issues concerning
toxicity, disposal, ventilation, lack of training and the long contact times
required to achieve sterilization. Additionally it is difficult to monitor and
confirm that sterilization has been achieved and the packaging of items to
maintain sterility is not possible when chemical sterilants are used. These
products must always be diluted, used and disposed of according to the
manufacturer’s directions.
5.5.1
General Sterilization Requirements
i.
Instruments that penetrate the skin or mucous membranes (critical
items) shall be sterile prior to use. These items may either be
supplied sterile as pre-packaged, single-use disposable items or
they may be provided as reusable items that must be cleaned,
sealed in appropriate packaging and then sterilized on site before
each use.
The use of pre-packaged, sterile, single-use, disposable items are
recommended. Critical items must be sterilized.
ii. For items purchased as pre-packaged and sterile the PSS must
maintain a record of all information required for tracking purposes
(e.g. name of company that manufactures/sterilizes the needles).
iii. Following sterilization, instruments must be stored in a manner that
protects them from contamination. Therefore:
a) Items/instruments that are intended to pierce skin or
penetrate sterile tissue shall be maintained in sterile
packaging until time of use.
b) The best means of avoiding contamination is appropriate
packaging of instruments prior to the sterilization procedure
or the use of sterile single-use (pre-packaged, disposable)
supplies.
c) Packaging shall be specific to the sterilizer being used. Use
only packaging materials that are specifically designed and
manufactured for use in sterilization. Incorrect packaging can
inhibit sterilization or fail to properly protect the contents after
sterilization.
d) Sterility must be maintained until point of use.
24
e) The shelf life of a sterile package is event related rather than
time related. Event related shelf life is based on the concept
that items that have been properly decontaminated,
wrapped, sterilized, stored and handled will remain sterile
indefinitely, unless the integrity of the package is
compromised (i.e. open, wet, dirty).
f) Equipment/devices purchased as sterile must be used
before the expiration date if one is given.
g) Sterile packages that lose their integrity must be re-sterilized
prior to use.
h) Reprocessed equipment/devices shall be stored in a
clean, dry location in a manner that minimizes
contamination or damage.
i) Equipment/devices must be handled in a manner that
prevents contamination of the item.
j) Containers used for storage of clean equipment/devices
should be moisture-resistant and cleanable (i.e. cardboard
boxes must not be used).
k) Store equipment/device in a clean, dry, dust-free area
(closed shelves), not at floor level. Equipment/instruments
should be at least one meter away from debris, drains,
moisture and vermin to prevent contamination.
l) Store equipment/device in an area where it is not subject to
tampering by unauthorized persons.
m) Transport processed equipment/device in a manner that
avoids contamination or damage to the equipment/device.
n) At point of use, upon opening the reprocessed
equipment/device, check for integrity of the packaging
and the equipment/device; validate results of chemical
monitors if present; and reassemble equipment/device if
required.
o) Provide education to those opening sterile items at point of
use. Education should include inspection, interpretation of
monitors and reassembly of equipment/devices.
25
p) Validate results of chemical tape and internal monitors if
present.
q) Visually inspect the equipment/device for discoloration or
soil. If present, remove from service and reprocess.
r) Check for defective equipment/devices and remove from
use.
s) If sterile package has become damp or wet (e.g. high
humidity), reprocessing may be required.
iv. Sterilized, reusable instruments/ items, that become contaminated
must be cleaned and re-sterilized prior to use.
v. Contaminated disposable items must be appropriately discarded
and not reused.
vi. If a package of reusable sterilized instruments is
damaged/compromised, that instrument must be reprocessed. If
the instruments are single-use, they must be discarded.
vii. Autoclaves, chemical autoclaves and dry heat sterilizers must be
serviced on a regular basis according to the manufacturer’s
operating instructions and their operation monitored routinely.
Always follow the sterilizer manufacturer’s instructions for
installation, operation, testing and maintenance. Manufacturer’s
instructions must be kept on site and be readily accessible.
There are three forms of monitoring required to ensure sterilization is achieved:
a. Physical (Mechanical) Monitoring
i)
ii)
a record/log must be maintained on site for monitoring each load,
including recording the temperature, duration, pressure, date, initials
of the individual who is responsible for sterilization of the load. It is
recommended that the autoclave be equipped with a print-out that
provides details of the mechanical parameters reached during each
cycle. This print-out must be signed and dated by the operator and
kept in the log book.
monitoring records must held in a secure location on site for a
minimum of one year, and on file for five years.
b. Chemical Monitoring (Process monitoring)
i)
ii)
during each sterilization cycle, every instrument/package must have
a temperature sensitive indicator, (e.g. tape or label) which changes
colour if the packaged item was processed.
the indicator must be specific to the type of sterilizer being used
26
iii)
iv)
solely reaching the required temperature does not ensure
sterilization. While the colour change provides an instant visual
verification that each package has been processed, chemical
indicators do not provide proof that sterilization has occurred as other
essential parameters (i.e. time and/or pressure) must be taken into
account
in accordance with (iii) above, biological monitoring must also be
carried out
c. Biological Monitoring
i)
each sterilizer actively used must pass a spore test challenge biweekly (i.e. every other week) at a minimum.
ii) results must be accessible on site for a minimum of one year and
kept on file for 5 years.
iii) prior to using a new sterilizer, or after repair of a used machine, the
operator must demonstrate the sterilizer is working properly through
three consecutive negative tests (i.e. no spore colony growth) with a
commercially available preparation of heat resistant spores. The
three tests may be run one after another on the same day (i.e. three
different loads). The sterilizer must not be used until results of the
spore testing are available.
iv) if back up sterilizers are used they shall demonstrate three
consecutive negative spore strip test results prior to use.
v) if spore strips are used, they must be packaged in the same manner
as equipment prior to inserting into the sterilizer.
vi) after exposure in the sterilizer, the spore strips must be sent to an
accredited laboratory as defined by the Laboratory and Specimen
Collection Centre Licensing Act for testing.
vii) results must be returned to the owner/operator responsible for the
personal services setting for follow-up action as required. The owner
is responsible for following up with the laboratory in order to obtain
spore testing results in a timely manner.
viii) test results shall be stored on the personal services settings for a
minimum of one year, and on file for 5 years.
ix) personal services settings should be prepared in the event the
mechanical sterilizer malfunctions.
x) personal services settings should provide alternate means of
sterilization, or stop services that are invasive in nature, or use
single-use disposable instruments.
xi) written back up plans may include: always having an adequate
supply of packaged, sterilized equipment; purchasing of an additional
autoclave; or a pre-arranged agreement with the autoclave
manufacturer to loan the premise an autoclave while the original is
being repaired. Back up plans are to be reviewed annually.
xii) prior to re-use of a repaired sterilizer, or use of a new sterilizer, you
27
must obtain three consecutive negative (no growth) spore strip test
results from an accredited laboratory.
xiii) reprocess all instruments/items that were sterilized during the time of
the failed test prior to re-use.
xiv) test results must be provided to the local health unit for review, prior
to resuming use of the sterilizer.
Note: Geobacillus (formerly Bacillus) stearothermophilus spores are used
to test steam sterilizers and Bacillus atrophaeus (formerly Bacillus subtilis)
spores are used for dry heat sterilizers.
“Negative” test results (no spore growth) indicate that the mechanical sterilizer is
operating properly. “Positive” test (spore growth observed) results mean the
sterilizer has failed and is not operating effectively. Discontinue use of this
sterilizer until it has been serviced and demonstrates three consecutive negative
tests prior to being used to sterilize instruments again. An alternative method of
sterilization or single-use/disposable sterile instruments must be used in the
interim. Sterilizers must then continue to be challenged with a spore test once biweekly (at a minimum). If a control strip is used, it must demonstrate growth
(non-sterile).
What to do in the event of a positive (failed) spore test:
i)
The PSS Owner/operator shall contact their local health unit for
every sterilizer failure (positive test) immediately upon
notification from the laboratory.
ii)
Repeat the test. Do not release any items that were processed
since the last negative test. If this repeat test is negative, and there
is not an indication of a system malfunction – continue as normal. If
it has been determined that the sterilizer malfunctioned, have it
repaired and then biologically tested until negative results are
obtained
iii)
If the repeat biological indicator test is positive again, review all
items that were processed since the last negative test. Review the
process to ensure this is not a false positive. Complete a report that
includes time, date, load description, results of mechanical and
chemical monitoring and contact the local health unit to facilitate
the conduction of a risk assessment.
Chemical Integrators
Integrators respond to critical parameters (e.g. time and temperature) and
provide immediate results enabling PSSs to respond more quickly to sterilizer
problems. While integrators can provide results between bi- weekly use of
28
biological indicators, use of chemical integrators do not replace the routine use
of biological indicators.
5.6
Disposal of Equipment and Waste
Waste material and other garbage must be placed in receptacles and
disposed of in the regular garbage in a sealed bag. Waste that is
contaminated with blood or body fluids must be placed in a single, leak
proof bag. Sharps including needles, needles attached to syringes, and
blades, broken glass or other materials capable of causing punctures or
cuts and which have come into contact with human blood or body fluids
must be placed into an approved sharps container and disposed of as
biomedical waste. Local waste management authorities should be
consulted to determine any additional requirements for waste handling.
5.7
Record Keeping
Documentation of procedures and clients is essential to allow the PSS
owner to conduct investigations.
Client records must be kept on site for settings that offer invasive
procedures such as body piercing, tattooing, micro-pigmentation,
electrolysis and acupuncture. The records are to include:
i)
date of procedure and full name (first and last) of personal service
worker
ii)
client name (first and last), complete mailing address and telephone
number,
and
iii)
details of the procedure carried out.
The PSS owner must keep records on site for a minimum of one year, and on file
for a minimum of 5 years. Information is to be collected and stored in accordance
with local and provincial privacy legislation.
29
6.
6.1
HEALTH AND PERSONAL HYGIENE
Occupational Health and Safety
i.
The PSW must ensure that their own health does not in any way
endanger the health of clients. If you have a potentially
transmissible disease, it is recommended that you seek an
assessment from your health care provider regarding the potential
for transmission to clients. For example, if the PSW has a febrile
respiratory illness (cough or sore throat and fever) or a
gastrointestinal illness (diarrhea and/or vomiting), this is usually a
good indication that they should stay home.
ii.
The PSW must follow the principles of Routine Practices at all time.
Hand hygiene must be performed before and after each client or as
necessary during the procedure or interruptions in service (glove
changes, etc.).
iii.
The PSW must refrain from eating, smoking or drinking while
providing the service in the service area and must comply with local
smoking regulations.
iv.
The PSW should wear clean outer clothing when providing
personal services.
v.
Health and safety concerns that a PSW may have about workplace
conditions should first be brought to the attention of their employer
or supervisor. Employers are required under the Occupational
Health and Safety Act (OHSA) to take reasonable precautions in
the circumstances for the protection of workers. Precautions would
depend upon the hazards associated with the work. Ministry of
Labour inspectors will investigate workplace specific occupational
health and safety concerns that remain unresolved by the employer
to ensure that workplaces are in compliance with the OHSA and its
regulations.
Immunization to protect against Hepatitis B and yearly influenza immunization
should be considered for all PSWs. Hepatitis B immunization is strongly
recommended for those providing invasive procedures.
6.1.1 General Hand Hygiene Principles
i.
PSWs must perform hand hygiene and then put on single-use
gloves prior to providing services to each client.
30
6.2
ii.
Single-use gloves must be worn for invasive procedures, (i.e.
tattooing, piercing, acupuncture or electrolysis, etc.) and where
there is a risk of exposure to blood or body fluids.
iii.
Single-use gloves must be changed between clients, and between
breaks in treatment of the same client.
iv.
Hands must be washed thoroughly for at least 15 seconds with
soap and warm running water once service is completed and after
gloves are removed. Alternatively, an alcohol-based hand rub (6090% alcohol) may be used if hands are not visibly soiled.
v.
Hand lotion (emollients) should be available for PSWs to prevent
dry or cracked skin. Lotions should not be petroleum based, as
such products could affect glove integrity.
Health of the Client
The PSW must ensure that any part of the client’s body to be treated is
clean and free from cuts, wounds, rash, fungus or visible skin disease.
For invasive procedures, the area to be treated must be cleaned before
treatment with an approved skin antiseptic (i.e. povidone-iodine solution,
chlorhexidine 2-4% chlorhexidine gluconate, 0.5% chlorhexidine gluconate
with 70% alcohol or 70% alcohol) and a single-use applicator. Once
applied, the skin antiseptic must be allowed to contact the skin for an
appropriate contact time before beginning any procedure.
The PSW must wear single-use gloves prior to dressing the wound.
Document any such incident and retain records on site for one year, and
on file for a minimum of 5 years. The client must be advised to consult a
physician should signs of an infection appear.
Note: If a non-sterile instrument accidentally punctures a client’s skin,
allow the wound to bleed freely, apply a skin antiseptic and treat the wound
as described in 7.2
31
7.
BLOOD AND BODY FLUID EXPOSURE RESPONSE
PROCEDURES
7.1 Causes of Exposure
Blood and body fluids may contain pathogens such as hepatitis B virus
(HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV).
The following could result in exposure to blood-borne pathogens:
i)
ii)
iii)
a needle stick or cut from a sharp object contaminated with blood
and/or body fluid
blood and/or body fluid contact with broken skin (open cut, wound,
dermatitis), or
blood and/or body fluid contact with a mucous membrane (eyes,
nose, mouth).
7.2 Procedure for blood and body fluid exposure
Care must be taken to prevent accidental puncture wounds and abrasions
to the PSW and clients from needles, razors, glassware or other instruments
not intended to pierce the skin. Should such an incident occur:
i)
ii)
iii)
iv)
v)
wear single-use gloves prior to handling or dressing the wound
wash the exposed skin surface with water and soap. If the area is
bleeding, allow it to bleed freely. After cleaning the wound, apply a
skin antiseptic and cover with a clean dressing or bandage.
If there has been a splash on to a mucous membrane, flush the area
thoroughly with water
the person exposed must immediately contact a physician for
assessment of the need to receive post-exposure treatment or
prophylaxis
the PSW shall document all incidents and keep records on site for a
minimum of one year, and on file for 5 years.
Accidental exposures to blood or body fluids to the client or operator shall be
documented for PSS. A record of the incident must be kept by the owner or
operator of the settings including:
i)
ii)
iii)
iv)
v)
name (first and last), complete mailing address and phone number of
the person exposed
name of PSW (first and last) involved in the incident
date of injury
site of injury
circumstances surrounding the injury; and
32
vi)
action taken.
The PSS owner must keep records on site for a minimum of one year, and on file
for a minimum of 5 years.
Management of equipment inadvertently exposed to blood
The following process should be used whenever equipment is inadvertently
exposed to blood and or body fluids.
i)
ii)
Clean to remove organic material
Disinfect the equipment using the appropriate level of disinfection
ensuring adequate contact time.
33
8.
ADDITIONAL GUIDELINES FOR SPECIFIC PERSONAL SERVICES
All specific personal services described must also refer to general
guidelines. For specific requirements, refer to tables 4 to 7 as
applicable. Appropriate aftercare should be available for all personal
services.
8.1 Manicures, Pedicures and Nail Treatments
8.1.1
Nail Fungus, Nail “Mould”
Client’s nails must be carefully examined prior to providing nail
services. Nail fungus usually appears as a discoloration in the nail
that spreads toward the cuticle. Nail “mould” can often be identified
in the early stages as a yellow-green spot that becomes darker with
time.
Nail services must not be provided for a client who has this type of
discoloration on his or her nails. PSWs should not provide the client
with any fungal ointment or treatment. Clients with this condition
must be advised to see their doctor for appropriate treatment.
8.1.2
Additional Requirements to the General Guidelines
Recirculation systems (e.g. foot spa/bath) may be predisposed to
development of a biofilm layer, hence cleaning and disinfectant
solutions must be circulated through the system. Improper cleaning
and disinfection processes have been linked with several
mycobacterial outbreaks.
i.
Nail service equipment and instruments (including recirculation systems) must be cleaned and then intermediate
to high-level disinfected between clients.
ii.
Footbaths: After each use, the foot bath must be cleaned
with a detergent and water solution, rinsed and then
disinfected with an intermediate to high-level disinfectant
solution. Each (cleaning and disinfectant) solution must be
circulated through the footbath’s circulating system.
iii.
The disinfectant solution must be circulated for the minimum
specified contact time as per the manufacturer’s
recommendations. For bleach solutions refer to Table 8.
iv.
Footbaths that are equipped with a screen and recirculation
systems require additional maintenance. The screen must
34
be removed daily and cleaned to remove any debris that has
accumulated, followed by intermediate to high-level
disinfection.
v.
Pedicure blades must be discarded in an approved sharps
container immediately after use on each client.
vi.
Any styptic product used must be single-use and discarded
after each client. Styptic pencils cannot be used to stop
bleeding on clients. Powder or liquid form is acceptable
provided that if direct contact with the skin is required, that it
be applied by use of a disposable applicator.
8.2 Electrolysis and Laser Hair Removal
Electrolysis is a method of permanent hair removal. Common areas treated
include the chin, legs and eye brows. During electrolysis, an electric current
is conducted through a needle inserted into the hair follicle, destroying hair
growth cells.
The heat produced by the current passing through an electrolysis needle will
not cause the needle to become hot enough to be sterilized. The
temperature is only likely to reach 70-80oC and the period that the current
passes through the needle is too short (1-2 seconds only) for sterilization to
occur.
8.2.1
Additional Requirements to the General Guidelines
i.
Needles used for electrolysis must be single-use,
disposable, sterile. Never re-use needles.
ii.
The removable tip/cap of the epilator needle/probe holder
must be cleaned and at a minimum, disinfected with a highlevel disinfectant after each client. Refer to Tables 1 and 2.
iii.
The epilator cord may come in contact with the client's
treated skin. The cord must be protected with a non
absorbent single-use disposable cover and changed
between each client or cleaned then disinfected with an
intermediate or high-level disinfectant between clients.
iv.
Equipment/instruments used in laser hair removal must be
cleaned then either disinfected or sterilized or disposed of as
appropriate after each client. Refer to Cleaning (Section 5.2),
Sterilization (Section 5.5), and Tables 1 and 3.
35
v.
Reusable equipment/instruments used to remove ingrown
hairs must be cleaned and then sterilized after each use.
Equipment/instruments used to hold sterile items (e.g.
tweezers) shall be high-level disinfected at a minimum.
Single-use sterile needles are to be used to expose the
ingrown hairs. Equipment/instruments NOT used to remove
ingrown hairs, but used only to pull the hair, must be cleaned
and then disinfected with an intermediate or high-level
disinfectant between use.
8.3 Tattooing and Micropigmentation
8.3.1
Additional Requirements to the General Guidelines Before
Tattooing and micropigmentation
To prevent cross-contamination of the work environment:
i.
Only single-use, disposable, sterile needles may be used.
ii.
All supplies required for tattooing or micropigmentation are
to be assembled and set-up immediately prior to starting the
procedure.
iii.
Prior to using disposable ink caps that are supplied in bulk
quantities (e.g. many caps are contained in a bag), individual
ink caps must be cleaned and then disinfected with an
intermediate level disinfectant (e.g. 70%-90% isopropyl
alcohol) for 10 minutes.
iv.
After needles are attached to the needle bar, they must be
cleaned (i.e. using an ultrasonic cleaner) before sterilization.
v.
Disposable ink caps must be discarded immediately after
each client. Any leftover ink must be discarded. If additional
ink is required a new ink cap is required.
vi.
All reusable ink caps must be sterilized between clients.
Single-use ink caps are preferred. Ink cap holders are to be
high-level disinfected.
vii.
Liquid used for rinsing between colors must be placed in
disposable cups. The liquid and cups must be discarded
after each client.
viii.
A sufficient number of tissues or wipes required for use
during a tattoo or micropigmentation procedure must be
36
dispensed prior to the service. Any assembled unprotected
or unused tissues and wipes not used during the procedure
must be discarded after each client.
ix.
Do not tattoo or micropigment within six inches of inflamed
or infected skin, or skin with a rash.
8.3.2
Additional Requirements to the General Guidelines After
Tattooing and micro-pigmentation
Note:
Any handling and manipulation of used needles in any
manner, such as disassembling the needle bar from the
needles, increases the risk of needle stick injury for the PSW.
i.
The entire needle bar assembly (i.e. needle bar with
attached needles) must be discarded into an approved
sharps container immediately after each tattoo or
micropigmentation procedure. Used needles and needle
bars must not be handled or manipulated prior to being
discarded.
ii.
If a tattoo machine is not used for micropigmentation, the
needle holder device on the pen/instrument must be singleuse disposable or cleaned and then sterilized before it can
be used again.
iii.
Any leftover products must be discarded. They may not be
returned to their original containers and must not be used on
another client.
iv.
If stencils are used they must be single-use and discarded
at the end of the procedure.
v.
Reusable tubes must be disassembled, if appropriate, prior
to cleaning.
vi.
The tattoo must be covered with an individually packaged
dressing or bandage intended for covering wounds
vii.
Clients must be given verbal and written information
regarding tattooing after-care, such as:
a) discuss appropriate aftercare for tattooing and
micropigmentation
b) clean hands immediately before touching tattooed area
37
c)
discuss the expected healing time of the site with the
client
d) describe possible complications and their signs and
symptoms
e) advise on how to deal with slight redness, pain or
swelling and
f)
recommend consultation with a family physician if the
problem does not improve within 24 hours.
8.4 Body Piercing
8.4.1
Additional Requirements to the General Guidelines
i.
All jewellery used for body piercing must be sterile. If
piercing jewellery is made or modified by a piercer prior to
use, it may be cleaned manually, although use of an
ultrasonic cleaner is preferred, and then packaged and
sterilized by an acceptable method (refer to section 5.5).
ii.
As per section 6.2 i, the site/s to be pierced must first be
cleaned with an approved skin antiseptic, then marked with a
(iodine) felt tip pen to mark all body sites prior to piercing.
After one minute, once the pen mark has dried, the site/s are
to be cleaned again with the approved skin antiseptic just
prior to piercing. Single-use items (i.e. toothpicks, etc.) can
be used to mark such areas.
iii.
If using dermal punch method, (biopsy) tools must be
purchased as sterile, single-use disposable items. These
devices cannot be re-used and must be disposed of in an
approved sharps container immediately after use.
iv.
Closed ended receiving tubes must be sterile, single-use
and disposable. Open ended receiving tubes can be cleaned
with a wire brush and sterilized between uses.
v.
Following each piercing, all non-disposable equipment must
be cleaned and then sterilized.
vi.
Clients must be given verbal and written information
regarding body piercing aftercare, such as:
a) normal bathing and showering are permitted but
otherwise keep the pierced area dry
b) cleaning hands immediately before touching jewellery
38
c) turning jewellery when wound is not dry
d) allowing access of the wound to air by using a loose
covering
e) the expected healing time of the wound possible
complications and their signs and symptoms
f) how to deal with slight redness, pain or swelling and
recommend consulting a family physician if the problem
does not improve within 24 hours, and
g) advising not to remove the jewellery from a potentially
infected piercing and to contact the piercer and seek
medical advice.
Note: Any antiseptic may become contaminated if not handled using
aseptic technique. Recent studies have demonstrated persistent
contamination of an aftercare solution of benzalkonium chloride used for
cartilage piercing sites. Please note that Pseudomonas aeruginosa is
resistant to this antiseptic.
8.5 Ear Lobe Piercing
8.5.1
Additional Requirements to the General Guidelines
Ear piercing instruments shall not be used on any other part of the
body except the ear lobes (fleshy part only).
i.
If a needle or dermal punch method is used for piercing the
ear lobe refer to Body Piercing (Section 8.4).
ii.
The person performing the ear piercing must wear singleuse disposable gloves on both hands during the procedure.
iii.
Ear piercing instruments without disposable adapters or
cartridges are not recommended.
iv.
Ear piercing instruments without sterile, single-use
disposable plastic adapters or cartridges that come in direct
contact with the ear during the piercing procedure must be
cleaned and then sterilized between each client use. Refer
to Cleaning and Sterilization (Section 5.2 and 5.5) and
Tables 1 and 3. Many of the old style instruments (i.e. those
that do not have disposable single-use sterile cartridges or
plastic adapters or cartridges, but rather a fixed stud adapter
and/or a fixed clasp retainer) have plastic components that
are not capable of withstanding the sterilization process
without incurring damage. If the gun/instrument cannot be
sterilized, it must not be used.
39
v.
Ear piercing instruments must be loaded without touching
either the sterile jewellery or the stud-holding sterile,
(disposable) devices on the gun.
vi.
The piercing instrument equipped with disposable parts must
be cleaned and then disinfected with an intermediate to highlevel disinfectant after each client. Refer to Tables 1 and 2.
vii.
Jewellery must be supplied prepackaged and sterile.
Jewellery cannot be sampled or returned.
viii.
Do not spray sterile earrings with disinfectant solution prior
to piercing.
ix.
As per section 6.2 ii, the ear lobe must first be cleaned with
an approved skin antiseptic, then marked with a (iodine) felt
tip/marking pen prior to piercing. After one minute, once the
pen mark has dried, the site is to be cleaned again with the
approved skin antiseptic just prior to piercing.
x.
After each client, all disposable parts must be discarded.
Previously opened packages of jewellery can no longer be
considered sterile. Any jewellery stored in opened or
damaged packages may no longer be used to pierce the
skin.
xi.
Store the piercing instrument in a sanitary manner to prevent
contamination. Instruments that are sterilized must be stored
in a manner that maintains their sterility (refer to section on
sterilization and storage). Avoid touching the piercing
instrument unless hands are washed and single-use gloves
are worn.
xii.
Clients must be given verbal and written ear piercing aftercare, as in 8.4.1 section vi above.
8.6 Acupuncture
i)
ii)
iii)
Needles used to pierce the skin in acupuncture treatments are
critical items.
These needles must be supplied pre-packaged and sterile, and
discarded immediately after use since they cannot be adequately
cleaned. Never re-use needles.
Needles must not be saved to be reused on the same client.
40
iv)
If the acupuncture treatment is performed by a regulated health
professional, their practice does not require routine inspections by
health unit staff.
8.6.1
Additional Requirements to the General Guidelines
i.
All acupuncture needles that pierce the skin must be
supplied as prepackaged, single-use, disposable and
sterile. It is recommended the needles with plastic sheaths
(guiding tube) be used for acupuncture treatments. Do not
remove the plastic sheath prior to insertion in client.
ii.
Any item used to manipulate a sterile needle prior to
insertion must also be sterile.
iii.
Each individual needle must only be used on one site on the
same client.
iv.
The reusable handles for seven-star or plum-blossom
needles must be cleaned and then disinfected using a highlevel disinfectant after each client use.
v.
Sterile needles must not be placed on or in any non-sterile
environment (i.e. solution, cotton, foam, tray, etc.) before
use. It is recommended that needles be removed from
sealed packages in view of clients, just prior to insertion in
the client.
vi.
Care must be taken to touch only the upper part of the
needle (called the ‘handle’) when removing them from the
packaging, particularly when the needles are bundled
together. Any unused bundled needles must be discarded
after each client.
vii.
Instruments (i.e. tweezers, forceps) coming in contact with
the needle(s) after insertion into the client, must be cleaned
and then high-level disinfected between clients. Electrostimulation metal clips/hoops must be cleaned then
thoroughly wiped using an intermediate or high-level
disinfectant after each client.
viii.
Items used for cupping intact skin must be cleaned and then
low-level disinfected between clients.
ix.
Acupuncture should not be performed on non-intact skin.
41
8.7 Hairdressing/Barbering
i.
Any reusable surface cover that is not cleaned/laundered between
each client use must be used in conjunction with a single-use,
disposable sheet.
ii.
When a reusable protective cover is used around a client’s neck, a
sanitary strip or clean towel must be used to keep the protective
cover from coming into direct contact with the client’s neck. The
neck strip or towel must be discarded/laundered after each use.
iii.
Items, which only contact hair and not skin, are considered to be
non-critical and require, at a minimum, cleaning with soap or
detergent and a brush under running water between uses. A lowlevel disinfectant solution can be used to disinfect pre-cleaned,
non-critical items.
iv.
If a non-critical item, such as scissors or clippers, nicks the skin, it
must be processed as a semi-critical item before it can be reused.
Low-level disinfectant solutions cannot be used to disinfect semicritical items. An intermediate to high-level disinfectant is required
to process semi-critical items.
v.
Any blades used for shaving skin, must be single-use and
discarded in an approved sharps container immediately after use.
vi.
The handle and cradle of the razor, which holds the blade in place,
must be cleaned and disinfected as a semi-critical item after each
use. It is recommended to use razors that allow for easy cleaning of
the cradle.
vii.
A straight razor with a fixed blade (all in one piece, so the blade is
reusable and not disposable) is not recommended, as cleaning
sharps is hazardous to the PSW. If using a straight razor, it must be
cleaned and sterilized between uses.
viii.
Styptic pencils cannot be used to stop bleeding on clients. Powder
or liquid forms are acceptable provided that if direct contact with the
skin is required that it be applied by use of a disposable applicator.
ix.
Razors used for cutting hair must have a proper guard in place to
prevent the blade from coming in contact with the skin. Razors are
to be disposed of in an approved sharps container.
42
x.
The handle and cradle of razors used for cutting hair require no
processing and the blade can be reused, if only used for cutting
hair.
xi.
“Crochet hooks” used for cap highlights are considered semi-critical
items as they may scratch the scalp, and must be processed
accordingly after each use.
xii.
All disinfectant solutions must be made fresh daily, or according to
the manufacturers’ specification.
xiii.
All items must be cleaned and dried with a clean towel before they
can be placed in a disinfectant solution. Placing a soiled item in a
disinfectant solution contaminates the entire solution and therefore
contaminates all items placed in it.
xiv.
To achieve disinfection, items require full immersion in the solution
for the appropriate contact time instructed by the manufacturer.
xv.
Most hair salons and barbershops use a low-level disinfectant
solution, which is a quaternary ammonium compound. Since items
to be placed in quaternary ammonium compounds require cleaning
prior to immersion and rinsing after contact time in the solution, it is
recommended that the disinfectant solution be placed next to a
sink, as opposed to a workstation, to encourage proper use of the
disinfectant.
xvi.
Clean items must be stored separately to prevent cross
contamination with soiled items or surfaces. Never store clean
items and dirty items together. Do not store any item in a container
in which contaminated objects were placed or into a container that
cannot be cleaned due to the nature of its surface material.
xvii
Any needles used for hair weaves and extensions that contact the
client or operator must be discarded in an approved sharps
container immediately after contact.
43
REFERENCES
1.
Ontario Ministry of Health. Ontario Public Health Standards, 2008.
http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_sta
ndards/ophs/index.html
2.
Heymann D.L., Control of Communicable Diseases Manual 18th Edition.
2004
3.
Fauci AS, Clifford-Lane H. Human Immunodeficiency Virus (HIV)
diseases: AIDS and related disorders, in: Harrison’s Principles of Internal
Medicine 13th Edition, New York: McGraw-Hill Inc., 1994, pg 1567.
4.
Health Canada. Infection Prevention and Control Practices for Personal
Services: Tattooing, Ear/Body Piercing, and Electrolysis. 1999.
5.
Alberta Health. Health Standards and Guidelines for Personal Services,
1995.
6.
Dychdala GR. Chlorine and Chlorine compounds, in: Block SS,
Disinfection, Sterilization, and Preservation 4th Edition, Philadelphia: Lea
and Febiger, 1991, pg 146 and 1012.
7.
Cremieux A, Fleurette J. Methods of Testing Disinfectants, in: Block SS,
Disinfection, Sterilization, and Preservation 4th Edition, Philadelphia: Lea
and Febiger, 1991, pg 146 and 1012.
8.
Health Canada. Recommendations for Prevention of HIV Transmission of
Human Immunodeficiency Virus, Hepatitis B virus and other Blood borne
Pathogens in Health Care Settings. Canada Diseases Weekly Report
1988; 117-124.
9.
Health Canada. Hand Washing, Cleaning, Disinfection and Sterilization in
Health Care. 1998
10.
City of Toronto Public Health Department. Skin Piercing - Personal
Service Workers: Tattoo, Micro pigmentation, Electrolysis, Body
Piercing, 1995.
11.
Rutala W.A., Weber D.J. APIC Text of Infection Control and Epidemiology.
Chapter 55, Cleaning Disinfection and Sterilization. 2002
12.
CDC Guidelines for Infection Control in Health Care Personnel, 1998
13.
Alberta Health and Wellness. Health Standards and Guidelines for
Esthetics, June 2002
44
14.
British Columbia Ministry of Health and Ministry Responsible for Seniors.
Guidelines for Personal Service Establishments, 1995
15.
California Conference of Local Health Officers. Sterilization, Sanitation,
and Safety Standards for Tattooing, Permanent Cosmetics and Body
Piercing, 1998
16.
Gira AK et al. Furunculosis Due to Mycobacterium mageritense
associated with Footbaths at a nail salon. J Clin Microbiol. 2004 Apr;
42(4): 1813-1817.
17.
Vugia DJ et al. Mycobacteria in Nail Salon Whirlpool Footbaths, California.
Emerg Infect Dis 2005 Apr; 11(4): 616-8.
18.
Winthrop KL et al. An Outbreak of Mycobacterial Furunculosis Associated
with Footbaths at a Nail Salon. N Engl J Med 2002 May; 346 (18): 136671
19.
College of Physicians and Surgeons of Ontario, Infection Control in the
Physician’s Office, 2004 Edition.
20.
Mariano A, Mele A, Tosti ME, Parlato A, Gallo G, et al. Role of Beauty
Treatment in the Spread of Parenterally Transmitted Hepatitis Viruses in
Italy. Journal of Medical Virology. 2004 (74)
21.
Fisher CG, Kacica MA, Bennett NM. Risk Factors for Cartilage Infections
of the Ear. American Journal of Preventative Medicine. 2005.
22.
Keene WE, Markum AC, Samadpour M. Outbreak of Pseudomonas
aeruginosa Infections Caused by Commercial Piercing of Upper Ear
Cartilage. Journal of the American Medical Association. February 25,
2004.
23.
Redbord KP, Shearer DA. Atypical Mycobacterium furunculosis occurring
after pedicures. Journal of the American Academy of Dermatology. March
2006.
24.
Mayers et al. Mayo Clinic Proceedings 2002 77:29-34
25.
M.F. Loughlin, M.V. Jones and P.A. Lambert. Pseudomonas aeruginosa
cells adapted to benzalkonium chloride show resistance to other
membrane-active agents but not to clinically relevant antibiotics. J
Antimicrob Chemother (2002), pp. 631–639.
26.
Canadian Standards Association. Infection Prevention and Control in
Office-Based Health Care and Allied Services. Second Edition, 2004
45
Table 1 : Steps to Clean Instruments
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing,
Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Cleaning Process
Comments
Soak items that cannot be
immediately cleaned in a
container of clean warm water
with or without detergent in a
clean sink or in a labelled “dirty
instruments” container.
Put on thick rubber gloves
(non-medical gloves).
Soaking instruments prevents blood and other organic
matter from drying on the item. Do not soak dirty items
in hot water or in a disinfectant before cleaning, as this
can cause organic matter (dirt) to stick to the surface of
the object.
Take instruments apart and
rinse in a sink filled with
lukewarm water.
Prepare cleaning sink by adding
warm water and detergent.
Clean instrument surfaces by
using friction (washing and
scrubbing motions). Use a
brush to clean any crevices or
seams in instruments.
Inspect instruments to ensure
removal of all visible organic
matter.
Drain dirty water. Rinse cleaned
instruments under running
water.
Either air dry or dry with a
disposable towel.
Store cleaned instruments in a
covered container (can be
towel or clean storage area)
until disinfected or sterilized, as
required.
Clean and disinfect the sink.
Remove rubber gloves and
wash, rinse and, hang to dry.
Perform hand hygiene.
Thick rubber gloves suitable for cleaning have a wider bib
at the wrist to help prevent water from entering the inside
of the glove.
Hot water may cause organic matter (dirt) to stick to
objects.
To reduce the risk of injury, ensure that sharp objects are
visible by using low sudsing detergent according to
directions.
Scrub below the water surface to prevent splashing into
the eyes or onto clothing. An ultrasonic cleaner may be
used for cleaning. When using this device, the lid should
be closed to prevent aerosolization.
Organic matter prevents disinfection from occurring.
Rinsing removes residual detergent and soil that may
impair the function of the instrument or interfere with the
action of disinfectants.
If wet items are not dried a film may be left on the surface
which may contain pathogens.
Uncovered, clean instruments may become
contaminated by dust or moisture.
Sinks become contaminated during use, therefore,
cleaning and disinfection is required to reduce
microorganisms prior to reuse.
Cleaned rubber gloves may be used again as long as the
rubber is not torn or punctured.
Hand hygiene should be performed after removing
gloves.
46
Table 2 : Disinfection Chart *
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing, Ear/Body
piercing, and Electrolysis. Health Canada, July 1999. This chart is not intended to be inclusive of all
approved high, intermediate and low-level disinfectants.
Level of
Disinfection
HIGHLEVEL
Kills all
microorganis
ms (bacteria,
fungi and
viruses)
except
bacterial
spores
INTERMEDI
ATE- LEVEL
Kills most
bacteria,
fungi, viruses
and
mycobacteri
a
(tuberculocid
al)
LOW-LEVEL
Kills some
viruses
bacteria, and
fungi
When to Use
Use on semicritical items
Items that come
into contact with
nonintact skin or
mucous
membranes but
do not penetrate
them
Use on semicritical items
As above
Disinfectant Active
Ingredients
Contact Times
(Approximately)
Advantages
Disadvantages
1:50 chlorine bleach**
solution (1 part bleach and
49 parts water)
1,000 ppm (parts per
million)
> 20 minutes
Inexpensive, fast acting
Corrodes metal, may
destroy adhesives
with prolonged
soaking
2% gluteraldehyde (not
recommended for personal
service settings)
45 minutes
Follow Manufacturer’s
instructions
Non-corrosive to metal,
rubber or plastics, reusable
Toxic fumes,
expensive. (Not
recommended for PS
settings)
6% hydrogen peroxide
45 minutes
Follow Manufacturer’s
instructions
Environmentally friendly, no
residue
7% stabilized hydrogen
peroxide
30 minutes
Follow Manufacturer’s
instructions
Environmentally friendly, no
residual, irritant to skin or to
respiratory tract
0.55% orthophthalaldehyde (OPA)
10 minutes
Follow Manufacturer’s
instructions
Fast acting, no mixing needed
Oxidizing properties
may be destructive to
some equipment
(brass, zinc, copper
and nickel/silver).
Oxidizing properties
may be destructive to
some equipment
(brass, zinc, copper
and nickel/silver).
Stains proteins
70-90% isopropyl alcohol
10 minutes
Fast acting, leaves no residue
Can damage rubber
and plastics
70-90% Ethyl alcohol
10 minutes
Fast acting, leaves no residue
1:50 chlorine bleach**
(1 part bleach and 49 parts
water)
>10 minutes
Inexpensive, fast acting
Can damage rubber
and plastics.
Flammable
Corrodes metal, may
destroy adhesives
with prolonged
soaking
Quaternary ammonium
Follow manufacturer’s
instructions
Good cleaning agent for
environmental surfaces
Cannot be used on
instruments, not
recommended as an
antiseptic
1:500 chlorine bleach**
Inexpensive, fast acting
Corrodes metal, may
>10 minutes
solution (1 part bleach and
destroy adhesives
499 parts water) or 100
with prolonged
ppm
soaking
3% hydrogen peroxide
10 minutes
Environmentally safe
Oxidizing properties
may be destructive to
some equipment
(brass, zinc, copper
and nickel/silver).
Phenols
Follow manufacturer’s Easy to obtain, cleans and
Residual phenols on
instructions
disinfects
porous materials may
cause tissue irritation
even when
thoroughly rinsed.
For environmental
surfaces only
* Please adhere to manufacturer’s instructions for use, some disinfectants may require rinsing after use ** Based on 5.25% chlorine
bleach
Use on noncritical items.
Items that
contact intact
skin and not
mucous
membranes, or
items that do not
ordinarily touch
the client.
May be used for
routine
housekeeping
47
Figure 1: Cleaning, disinfection and sterilization flowchart
Adapted from Durham Region Health Department
FIRST STEP
CLEAN
Use detergent, clean water and a clean
brush
Note: An ultrasonic cleaner can be
used
RINSE
SECOND STEP
To destroy most harmful
germs (except spores)
To loosen dirt and debris on
surfaces
To remove soap residue, loosened
dirt and debris from surface
To kill all
germs &
spores
Choose one of the following
THIRD STEP
Use an appropriate solution
depending upon use of
instrument or surface
Choose one of the following
LOW-LEVEL DISINFECTION
To be used on:
• Non- Critical Items
• Items that contact but do not
penetrate skin
• Items that do not contact blood or
body fluids
STERILIZE
Use an appropriate and
approved sterilizer
To be used on:
• Critical Items
• Items that penetrate
skin
• Items that hold
sterile instruments
(in some cases,
high-level
disinfection is
appropriate)
INTERMEDIATE OR HIGH-LEVEL
DISINFECTION
To be used on:
• Semi-critical Items
• Items that contact mucous
membranes
• Items that contact non-intact skin
48
Table 3: Steps to Sterilization of Instruments
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing,
Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
1.
2.
Steps
Clean instruments as per Table 1: Steps
to clean instruments.
Perform hand hygiene and apply gloves.
3.
Clean instruments/equipment must be
placed in the appropriate sterilization
package and sealed.
4.
Temperature sensitive chemical
indicators must be used with each
package.
5.
Load the sterilizer evenly and avoid
overloading the chamber. Follow
manufacturer’s directions for loading the
chamber.
Start the sterilization process.
6.
7.
After the sterilization cycle has been
completed, remove instruments.
8.
Store sterilized items in a clean, dry
place that is protected from dust, dirt,
and moisture. Sterile items must be
stored off the floor.
9.
Record information about each
sterilization cycle in the log book.
Comments
Instruments that are not clean cannot be
sterilized.
Hands should be as clean as possible to
prevent contamination of clean
instruments/equipment.
Sealed packaged items will maintain sterility
after sterilization has been achieved until
opened for use. If packaging becomes wet or
damaged, sterility cannot be ensured.
Instruments in damaged packages must be
resterilized or discarded. Ensure packaging is
appropriate for type of sterilizer used.
Temperature sensitive chemical indicators
provide an immediate visual check to ensure
package has been processed. Note: The colour
change demonstrated by a chemical indicator
does not ensure that the processed items have
been sterilized. Only an appropriate biological
indicator can confirm that the sterilization cycle
has been successful.
Overloading the sterilizer will prevent effective
sterilization; allow space between the packages.
Sterilizing time, temperature, pressure and
cycles may vary depending on the type of
sterilizer used. Follow manufacturer's
instructions at all times. With dry heat and
autoclave sterilization, time does not start until
the appropriate temperature has been reached.
Ensure items are dry before removing from the
unit. Sterilized instruments may become
contaminated when wet packaging is handled.
Handling increases the chances of punctures of
sterilized bags. Sterilized items must be stored
separately from dirty equipment/instruments.
Monitor each load, recording temperature,
pressure, cycle length, etc.
49
Table 4:
Detailed Infection Prevention and Control Procedures for
Electrolysis
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing,
Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
1
2
Client
preparation
Skin
preparation
Equipment/
Supplies
single-use paper
or laundered towel
Use During Electrolysis
Drape the towel around
electrolysis treatment
area of the client.
eye shields
Protect client’s eyes from
injury and lamp glare
during electrolysis
involving the face.
wet sponge pad
with holder
Hold in client’s hand to
complete the electrical
circuit in the
galvanic/blend (not
thermolysis) method.
dental lip rolls
Lip rolls may be used to
create a taut skin surface
for electrolysis, e.g. the
upper lip.
A topical anesthetic may
be used to decrease
client discomfort during
electrolysis.
topical anesthetic
(optional)
skin antiseptic
clean swabs, e.g.
cotton balls,
gauze or singleuse cotton
applicators
pump pack
containing the
antiseptic
A non-irritating antiseptic
is used to cleanse the
skin before electrolysis.
Procedures for Infection
Prevention
The towel offers added
protection for supplies and
equipment that may touch
surfaces near the treatment
area, e.g. the client’s clothes.
After each client service,
detergent and water must be
used to clean the eye
shields, followed by low-level
disinfection.
The sponge pad should be
cleaned in detergent and
water after client use. The
single-use conductive gel
pad must be discarded after
client service.
Dental lip rolls shall be
discarded after each client
service.
Whenever a topical
anesthetic is used on a client
site, it must be applied with a
clean, single-use, disposable
swab. The anesthetic should
be applied on the site before
the skin in cleansed with an
antiseptic.
Antiseptic should be applied
to the clean swab using a
pump pack. Pre-packaged
antiseptic swabs may be
used.
Care should be taken to
avoid the antiseptic coming
into contact with the eyes
and mouth during
electrolysis. Cotton
applicators moistened with
water may be used to clean
the treatment area near the
eyes.
50
3
Epilator
Equipment/
Supplies
client sponge
holder cord
Use During Electrolysis
needle holder and
cord
4
Instruments
button/knob
controls
Conducts the electric
current for electrolysis.
Button/knobs are to
control current intensity
and times.
electrolysis needle
or needle and cap
combination unit
An electric current is
passed through a
specialized needle that
has been inserted along
the hair follicle.
Procedures for Infection
Prevention
The epilator button/knob
controls shall be cleaned
then wiped with a low-level
disinfectant after each client
service or covered with
single-use plastic. Since the
cords may come in contact
with the area being worked
on, the cords shall be
covered with single-use
plastic or cleaned then
disinfected with an
intermediate to high-level
disinfectant.
Pre-packaged sterile, singleuse, solid needles or a
combination unit (sterile
needle permanently attached
to the plastic cap) must be
used.
Needles must not be tested
on the practitioner’s skin.
Needles must not be saved
for reuse for future
treatments on the same
client.
The needle must not be
recapped prior to disposal in
an approved sharps
container.
hypodermic
needle or lancet
The hypodermic
needle/lancet should be
used to lift or remove
ingrown hairs.
Used electrolysis needles
must be discarded into an
approved sharps container
immediately after each
client.
Sterile, single-use prepackaged hypodermic
needles/lancets should be
used to lift or remove
ingrown hairs and shall be
discarded into the sharps
container after use on each
client. Never re-use
needles or lancets.
This procedure breaks the
skin tissue and usually
draws some blood; therefore
the electrologist shall wear
single-use gloves.
51
Equipment/
Supplies
tweezers or
forceps
5
6
Needle holder
Additional
supplies
Use During Electrolysis
Tweezers should be used
to lift and hold the hair
during electrolysis and
may be used to lift
ingrown hair.
scissors
Scissors may be used to
cut hair before
electrolysis.
metal pin device
The electrolysis needle is
inserted or screwed into
the prongs of the metal
pin device.
reusable plastic
needle holder tip
or single-use
combination unit,
i.e. needle and
needle holder tip
or cap in one unit
The reusable, plastic
needle holder tip that is
screwed on or the cap of
the single-use
combination unit that
covers the pin device to
prevent electric shocks to
the practitioner.
tray, e.g. metal or
glass
magnifying lamp
and the arm
holding it/glasses
or microscope and
light source, e.g.
lamp
“dirty instrument”
container with lid
(containing water
or detergent and
water)
Rest instruments/
supplies on the tray
during the procedure.
Permits visualization of
the treatment area.
Used instruments are
stored in water or a
detergent and water
solution to prevent drying
of body proteins onto
instrument prior to
manual or ultrasonic
cleaning.
Procedures for Infection
Prevention
Tweezers must be sterile if
used to break skin and
remove ingrown hairs or
high-level disinfected if used
to load a sterile needle into
the epilator. Tweezers must
be cleaned and packaged
before sterilization.
Scissors shall be cleaned
and disinfected with an
intermediate-level
disinfectant after each client
service.
The permanently attached
pin device must be cleaned
then disinfected with a highlevel disinfectant, after each
client service.
The reusable, screw-on,
plastic needle holder tip
should be cleaned with a
pipe cleaner after each client
service and must be
disinfected with a high-level
disinfectant, and stored dry.
The needle shall not be
recapped prior to disposal in
an approved sharps
container to reduce the risk
of needle injury to the
practitioner.
Trays shall be cleaned then
low-level disinfected after
each client service.
Equipment surfaces touched
by the practitioner shall be
cleaned then disinfected with
a low-level disinfectant after
each client. Alternatively,
surfaces may be covered
with single-use plastic that is
discarded and changed
between each client.
The dirty instrument
container must be cleaned
daily and then subjected to
low-level disinfection. The
solution in the container
must be changed daily.
52
7
Client
aftercare
Equipment/
Supplies
ultrasonic
cleaner/manual
cleaning
Use During Electrolysis
sharps container
Electrolysis needles or
lancets must be
discarded into an
approved sharps
container immediately
after use.
An antiseptic that
cleanses the skin.
skin antiseptic
swabs
ointment or mild
astringent
An ultrasonic cleaner that
contains detergent and
water may be used to
clean instruments.
Ointment/astringent may
be used to soothe the
skin and promote skin
healing.
Procedures for Infection
Prevention
The ultrasonic cleaner must
be cleaned daily with
detergent and water. A fresh
solution of detergent and
water shall be placed in the
device each day. If solution
becomes visibly dirty
ultrasonic cleaner should be
emptied, cleaned and filled
with fresh solution. The
ultrasonic cleaner does not
sterilize the instruments.
If manual cleaning is done,
follow the instructions
outlined in 5.2.2
Puncture-resistant sharps
containers must be used to
help prevent needle injuries.
Antiseptic should be applied
with a clean swab dispensed
from a pump pack containing
the antiseptic or prepackaged single-use
antiseptic swabs should be
used.
A single-use wooden tongue
depressor or spatula should
be used to remove ointment
from a bulk container to
apply to the skin. If removing
a large amount of ointment,
use a single-use
spatula/tongue depressor
and dispense into a smaller
single-use container. The
spatula must be discarded
into a waste bin after singleuse. Do not double dip.
Apply astringent or ointment
with a clean swab or clean
gloved hands.
Clients shall be instructed to
avoid touching skin that has
undergone electrolysis or to
touch only with washed
hands. The client should
avoid using make-up or any
cosmetic products in the
area that has been worked
on according to the
practitioner’s advice.
Clients shall be given written
aftercare instructions.
53
8
Practitioner
supplies
Equipment/
Supplies
Use During Electrolysis
Procedures for Infection
Prevention
hand washing
soap
Soap is used to remove
dirt and some
microorganisms from the
practitioner’s hands.
Refer to
alcohol-based
hand rubs
hand lotion
single-use gloves
(e.g., latex,
neoprene, nitrile,
or vinyl)
general recommendations
Section 6.1.1
Alcohol-based hand rubs
containing between 6090% alcohol can be used
to perform hand hygiene
when hands are not
visibly soiled.
Lotions are used to
prevent skin from drying
and cracking and to keep
the skin in good
condition.
Single-use gloves must
be worn when hands are
expected to come in
contact with blood or
body fluids. Gloves shall
also be worn when
working on an infected
hair follicle, or if the
practitioner has cuts or
other breaks in the skin.
Single-use gloves must be
worn for all procedures
involving:
• breaking through skin
•
expected contact with
mucous membranes
• expected contact with
blood or body fluids.
Single-use gloves act as a
barrier and reduce the
potential transfer of
microorganisms between the
client and the electrologist.
Hand hygiene must be
performed before gloves are
applied and after glove
removal.
Gloves are not a substitute
for hand hygiene
Cuts/breaks in the skin shall
be covered with a waterproof
dressing before the gloves
are applied.
54
Table 5: Detailed Infection Prevention and Control Procedures for
Body Piercing
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing,
Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
Equipment/
Supplies
Use During Skin
Piercing
Procedures for Infection
Prevention
The towel should be used to
protect the client from any
soiling during the procedure.
The towel must be laundered
after each client.
The skin antiseptic should be
applied with a moist swab,
using a circular motion. If
alcohol is used it should be
stored in a pump pack which
is used to moisten the swab
with alcohol. Other
antiseptics, e.g. betadine,
may be poured into a
disposable cup. If betadine is
used to prepare the skin
before genital piercing, any
excess antiseptic should be
removed to avoid irritation to
mucous membranes.
1
Client
preparation
single use towel
A towel may be used to
drape the piercing site.
2
Skin
preparation
skin antiseptic, e.g.
70% alcohol or an
iodine, such as
betadine. The
antiseptic selected
should be
appropriate for the
piercing site
according to the
manufacturer’s
instructions, e.g.
70% alcohol is
suitable for
application to skin
but should not be
used on mucous
membranes.
Swabs moistened with an
antiseptic are used to
disinfect the skin piercing
sites.
Warm water is used to
cleanse areas around the
eyes.
clean swabs, e.g.
gauze or cotton
balls
3
Skin marking
antibacterial mouth
wash
Mouthwash is used as an
antiseptic before piercing
the tongue.
calipers
Calipers are used to
measure skin piercing
sites to create a
symmetrical appearance.
Antibacterial mouthwash
cleans the mouth prior to
tongue piercing if used for
several minutes.
Calipers shall be cleaned
then disinfected with a lowlevel disinfectant if the skin is
intact.
Calipers used on mucous
membranes shall be highlevel disinfected.
55
Equipment/
Supplies
Use During Skin
Piercing
Procedures for Infection
Prevention
tooth picks and ink,
Tooth picks, dipped in ink
mark the piercing site(s).
A few drops of ink should be
placed on a clean surface,
e.g. the inner surface of the
e.g. gentian violet
wrapper used for a sterilized
item, to avoid dipping the
tooth pick into the ink
container itself. The site/s to
be pierced must first be
cleaned with an approved
skin antiseptic, then marked
with a (iodine) felt tip pen
to mark all body sites prior to
piercing. After one minute,
once the pen mark has dried,
the site/s are to be cleaned
again with the approved skin
antiseptic just prior to
piercing.
forceps
elastic bands
4
Service tray
a tray that is
smooth, nonporous
and easy to clean,
e.g. metal
Forceps should be used
to hold the marked skin
taut for the needle
piercing. They may
become contaminated
with blood during the
procedure.
Elastic bands are used to
hold the handles of the
forceps closed to ensure
secure gripping of the
skin surface.
The tray is covered with a
clean towel. Sterile
instruments and other
supplies, e.g. lubricant,
cork, elastic bands, and
any additional required
items should be placed
on the towel. The sterile
needle, jewellery, and
forceps should be left in
the opened packages
until just before use. The
tip of the needle must not
be touched prior to
insertion.
Forceps must be cleaned
and sterilized after use on
each client.
Clean elastic bands should
be stored in a covered
container and discarded after
use. Forceps should be used
to remove the elastics from
the container at the outset of
the procedure to avoid
contamination of other
elastic bands in the
container.
The tray must be cleaned
then wiped with a low-level
disinfectant after use.
The towel shall be a single
use disposable or freshly
laundered cloth.
56
5
Instruments
Equipment/
Supplies
single use hollow
skin piercing
needles, e.g.
stainless steel
Use During Skin
Piercing
The needle pierces the
skin/tissue and the
jewellery is inserted in
the channel created by
the needle.
needle pushers
(plastic)
The practitioner may use
needle pushers to push
the blunt end of the
needle through tissue.
insertion tapers
Insertion tapers are most
often used to upgauge or
put in a thicker piece of
jewellery into already
healed piercing.
Connectors are used to
facilitate the insertion of
internally threaded
barbells by providing a
link between the hollow
needle and the hollow
jewellery.
Receiving tubes are used
when piercing difficult to
reach areas, such as the
nostril or the glands of
the penis. The tube forms
a drum of skin into which
the piercing needle is
received.
Insertion tapers are to be
cleaned and sterilized after use
on each client.
Corks are used to cover
the sharp end of the
needle after it has
pierced through tissue
to prevent a needlestick
injury to the practitioner.
Clean, single-use corks
are to be discarded after one
piercing. It is not necessary
to sterilize the cork prior to
use as it does not come in
contact with open skin areas.
connectors (solid
metal)
receiving tubes
corks (single-use)
Procedures for Infection
Prevention
One new, sterilized piercing
needle should be used for
each client and each
procedure. The needle/s
must be discarded into the
sharps container after use.
Because the needle is hollow
it cannot be properly cleaned
or sterilized, therefore must
be discarded.
Needle pushers should
undergo sterilization
because of contact with the
sterile needle that will be
inserted through skin/tissue.
Specialized connectors
are to be cleaned with
small brushes in a solution of
detergent and water and
sterilized after use on each
client.
Closed ended receiving
tubes must be sterile, singleuse and disposable. Open
ended receiving tubes can
be cleaned with a wire brush
and sterilized between use.
The needle tip, which is
inserted into the cork, should
not be pulled back through
the freshly pierced tissue.
Instead, the cork and needle
shall be placed in the sharps
container.
57
6
Jewellery
Equipment/
Supplies
Use During Skin
Piercing
Procedures for Infection
Prevention
rings, studs, and
barbells are
common forms
Sterile jewellery is
inserted through the
needle channel and
secured.
Jewellery must be sterilized
before use.
Jewellery should be smooth
to avoid skin irritation, which
delays healing and increases
the composition of
jewellery is primarily
14-18
infection risk.
carat gold, titanium,
niobium or stainless
steel
(some steel
contains nickel)
ring opening pliers
Sterile ring pliers are to
be used to open and
close jewellery, taking
care not to scratch or
nick the metal.
Pliers are to be cleaned and
sterilized after each use.
The container is used to
store used instruments
prior to cleaning. Soaking
instruments
prevents drying of body
proteins.
The container shall be
cleaned and then
to low-level disinfected daily.
Sharps container
with secure lid
For the disposal of
piercing needles and cork
Approved sharps containers
must be used to help prevent
sharps injuries.
soap
Clients should be
instructed to wash their
hands before washing
the pierced area with
soap on a daily basis and
to rotate the jewellery to
help with the cleaning
process.
The skin piercing site must
be cleaned to promote
healing and reduce the
chance of infection. Oral and
written instructions for
aftercare are to be provided
to the client.
antibacterial
ointment
Ointment may be applied
to the freshly pierced skin
area and the jewellery
should be rotated.
If ointment is used, singleuse ointment applications
are recommended. Ointment
also acts as a lubricant and
may reduce the chance of
infection.
ring closing pliers
7
Additional
supplies:
container, e.g.
metal, with lid
cool water and
detergent
8
Client
aftercare
The solution in the container
shall be changed daily.
If ointment is taken from a
bulk container it is to be
removed with a single-use
spatula or tongue depressor.
Some people develop an
allergic reaction to the
ointment, and so some
practitioners do not use it.
58
9
Practitioner
supplies
Equipment/
Supplies
Use During Skin
Piercing
Procedures for Infection
Prevention
hand washing soap
Soap is used to clean the
practitioner’s hands of
microorganisms.
Alcohol-based hand rubs
containing between 6090% alcohol can be used
to perform hand hygiene
when hands are not
visibly soiled.
Refer to recommendations in
section 6 of the main
document.
alcohol-based hand
rubs
hand lotion
Lotions are used to keep
the skin in good condition
as frequent hand
washing may dry out the
skin.
clean medical
gloves, e.g. latex,
vinyl, neoprene, or
nitrile
Gloves shall be used as
a protective barrier on
hands after cleaning of
the skin with an antiseptic
and opening the package
that contains the sterile
needle. Gloves or forceps
are to be used to remove
the needle from the
package. If the gloves
are contaminated, they
shall be removed, hand
hygiene performed, and a
new pair put on.
Gloves shall be worn to
reduce the number of
organisms on the hands and
offer some protection from
sharps injuries.
Gloves should be used to
touch only the objects
needed to do the procedure.
Hand hygiene must be
performed before gloves are
applied and after glove
removal.
59
Table 6: Detailed Infection Prevention and Control Procedures for
Tattooing and Micropigmentation
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing,
Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
1
Skin
preparation
Equipment/
Supplies
Use During Tattooing
Procedures for Infection
Prevention
spray bottle with a
solution of soap
and water
The skin area to be shaved
is sprayed with the solution
for lubrication purposes.
The spray bottle shall be
covered with a single-use
plastic sheath (e.g. plastic
bag). This plastic shall be
discarded after each client
service. At the end of each
day, or when soiled, the spray
bottle shall be cleaned then
disinfected with a low- level
disinfectant.
The solution should not be
“topped up” with more solution.
The inside of the bottle should
be washed and dried prior to
adding new solution.
single-use
disposable razor
The skin is shaved prior to
tattoo placement.
Razors are to be discarded in
an approved sharps container
immediately after use on each
client.
topical anesthetic
(optional)
A topical anesthetic may
be used to decrease client
discomfort during the
procedure.
Whenever a topical anesthetic
is used on a client site, it must
be applied with a clean, singleuse, disposable swab. The
anesthetic should be applied
on the site before the skin in
cleansed with an antiseptic.
skin antiseptic
Antiseptic is used to
cleanse the skin prior to
tattooing.
The skin antiseptic is to be
applied with a clean swab
using a circular motion. If
alcohol is used, it should be
stored in a pump pack that is
used to moisten the cotton
balls. Alternatively, the swab
may be moistened by pouring
the antiseptic from the original
container into a disposable
paper cup. The disposable cup
is to be discarded in the waste
bin after use. Skin antiseptics
should not be sprayed onto
clients skin
For cosmetic tattooing of areas
around the eye, (e.g.
eyeliner), potable water should
be used and an antiseptic
should be avoided
.
60
2
Stencil and
image
transferring
solution
Equipment/
Supplies
Use During Tattooing
Procedures for Infection
Prevention
lotion or spray
bottle with solution
as above, skin
antiseptic
Lotion or other solution
moistens the skin prior to
application of the stencil.
Lotion should be applied in the
same way as skin
antiseptics OR with spray
bottle.
Deodorant sticks are not
recommended instead of lotion
since they can become
contaminated with
microorganisms and are
usually not discarded after
each client.
single-use stencil
transfers or plastic
stencils
Stencils are used to outline
the design of the tattoo on
the skin.
Single-use stencils shall be
discarded after use.
The lubricating product shall be
removed from the bulk
container with a single-use
wooden spatula or dispensed
from a pump container onto a
single-use applicator. Any
remaining product must be
discarded and never used on
another client. Alternatively, a
single-use preparation may be
used.
Currently, commercially
prepared pigments are not
sterile. Contamination of
pigment bulk containers should
be avoided by placing pigment
into smaller, clean containers,
(e.g. plastic squeeze bottles).
Pigments to be dispensed in a
manner that prevents
contamination.
3
Lubricating
product
e.g. gel or
petroleum jelly
The lubricating product is
placed on the skin with a
single-use spatula or a
piece of clean gauze prior
to tattooing.
4
Tattoo dyes
pigments/ink
Sterile needles, which have
been dipped into pigments,
pierce the tissue below the
skin to create the
permanent marks forming
the tattoo
pigment/ink
caps/cups
Each unique pigment is
placed in an individual
cap/cup into which the
tattoo needles are dipped.
Trays are sometimes used
to hold the pigment/ink
caps.
pigment/ink cap
holding tray
disposable cup
with tap water
Tap water is used to rinse
pigment/ink from the
needles prior to using
another colour.
The pigment/ink cap trays shall
be cleaned and high-level
disinfected as a minimum after
use for each client or
preferably are to be discarded.
Water should be poured into
the sink at the completion of
the procedure. Discard
disposable single-use cups into
a plastic lined waste bin.
61
5
Cleaning the
skin during
tattooing/micro
pigmentation
Equipment/
Supplies
Use During Tattooing
Procedures for Infection
Prevention
spray bottle
containing a
solution of soap
and water as in
#1.
The skin is cleaned to
enable the practitioner to
see it clearly and to avoid
the mixing of colours.
Care should be taken to
avoid contamination of the
soap solution when it is
being prepared and during
use.
The spray bottle shall be
covered and cleaned then
disinfected as in #1.
6
Tattoo
machine
single-use
disposable paper
towels
Single-use disposable
paper towels are used to
wipe the treated area
during the procedure.
All paper towels shall be
discarded into a plastic lined
waste bin, including any
unused paper towel in the
immediate work area.
motor frame
The motor frame is
connected to an electrical
source by the clipcord. The
clipcord may be touched
multiple times during
tattooing, especially if more
than one machine is used
on the client .
The clipcord and the motor
frame shall be covered with
a disposable plastic sheath.
The plastic sheath shall be
discarded after each client
service. The clipcord and
motor frame shall be cleaned
and then disinfected with a
low-level disinfectant after
each use.
Alternatively, surfaces may
be covered with single-use
plastic that is discarded and
changed between each client
After each client service the
clamp shall be cleaned then
disinfected with an
intermediate-level
disinfectant.
Elastic bands are single-use
and disposable.
clipcord
7
Instruments
chuck or clamp
The chuck/clamp attaches
the needle bar/tube to the
motor frame.
elastic bands
The elastic bands apply
pressure on the needlebar
so that the needles can
rest in the bottom of the
tube tip.
needles, e.g.
stainless steel
needle bars
Needles are soldered onto
needle bars. The needles
place pigments in tissue
under the skin.
Any flux residue produced by
soldering should be removed
with a solution of baking
soda and water or an
alternate appropriate
chemical prior to cleaning.
New needles and the needle
bar shall be cleaned, in an
ultrasonic cleaner, rinsed, air
dried, then sterilized or
packaged for sterilization
Needles must not be tested
on the practitioner’s skin.
62
Equipment/
Supplies
Use During Tattooing
Procedures for Infection
Prevention
Needles that have been
cleaned in the ultrasonic
cleaner between colours are
not sterile.
Used needle bar
combination shall not be
disassembled. Instead the
intact needle bar unit should
be discarded.
8
Other
equipment
metal tube and
grip (as one unit
or as separate
parts)
The metal tube and grip
assembly surrounds the
needle and needle bar and
is attached to the motor
frame,
Metal tubes and grip shall be
cleaned and sterilized for
each client use. Because the
grip is grooved metal, a
brush should be used during
cleaning. Tubes that can be
disassembled must be taken
apart to facilitate cleaning.
metal container
with lid or
puncture resistant
container
The container for used
instruments is kept in an
area designated for dirty
items/instruments, and is
partially filled with water, or
water and detergent to
prevent drying of body
proteins on soiled
instruments before
cleaning.
The metal container shall be
cleaned and disinfected with
a low- level disinfectant daily.
ultrasonic cleaner
The ultrasonic cleaner
contains detergent and
water to clean reusable
instruments after use on a
client prior to sterilization.
The ultrasonic cleaner is
also used to clean the
needles and needle bar
after the new unused
needles have been
soldered onto the needle
bar.
Cover the device with a lid
when in use.
The ultrasonic cleaner shall
be emptied and cleaned
daily with detergent and
water. The ultrasonic cleaner
cannot be used to disinfect
or sterilize instruments.
Needles cleaned in this
manner, (i.e. critical items),
shall not be reused.
approved sharps
container
For disposal of needles
and razors after each client
service (needles and
attached bar),
Approved sharps containers
shall be sealed and
discarded in accordance with
local regulations.
63
9
10
Client
aftercare
products
Practitioner
supplies
Equipment/
Supplies
Use During Tattooing
Procedures for Infection
Prevention
dry clean
dressing
ointment/cream/
lotion
The ointment or lotion and
dry dressing are applied to
freshly tattooed skin to help
prevent infection and
protect the client’s clothing.
Ointment shall be applied
with single-use applicator
and gloved hands in a
manner to prevent
contamination. The tattooed
skin is to be covered with a
dry clean dressing.
liquid hand
washing soap in a
dispenser
Soap is used to wash the
practitioner’s hands to
remove organic matter and
transient microorganisms.
alcohol-based
hand rubs
Alcohol-based hand rubs
containing between 6090% alcohol can be used
to perform hand hygiene
when hands are not visibly
soiled.
Lotion is used to prevent
skin from cracking and to
keep the skin in good
condition.
Single-use gloves are to be
used as a protective barrier
on hands.
hand lotion
clean medical
gloves
The client shall be given oral
and written instructions
about care of the tattooed
area, and signs of infection
that may require medical
treatment.
Refer to recommendations in
section 6.1.1
After the skin has been
cleaned with an antiseptic
agent and the packages
containing the sterile
needlebar(s)/sterile needles
have been opened, gloves
shall be put on to remove the
needlebar(s)/sterile needles
from the package and to
assemble them on the grip
and tube assembly.
Gloves shall be removed and
changed during the tattooing
process if, at any time, the
practitioner touches any
device or surface that may
be contaminated.
lap pad (singleuse paper or
reusable cloth)
Worn on the lap of the
practitioner to protect
clothing.
Hand hygiene must be
performed before gloves are
applied and after glove
removal.
Single-use, disposable lap
pads be used. If the lap pad
is cloth, it shall be laundered
after each client service.
64
Table 7: Detailed Infection Prevention and Control Procedures for Ear
Lobe Piercing
Adapted from Infection Prevention and Control Practices for Personal Services: Tattooing,
Ear/Body piercing, and Electrolysis. Health Canada, July 1999.
Equipment/
Supplies
Use During Skin
Piercing
Procedures for
Infection Prevention
The towel should be used
to protect the client from
any soiling during the
procedure.
The skin antiseptic shall
be applied with a moist
single-use swab, using a
circular motion. If alcohol
is used it should be
stored in a pump pack
which is used to moisten
the swab
with alcohol. Other
antiseptics, such as
betadine, may be poured
into a disposable cup.
The ear lobe must first be
cleaned with an approved
skin antiseptic, then
marked with a (iodine) felt
tip/marking pen prior to
piercing. After one
minute, once the pen
mark has dried, the site is
to be cleaned again with
the approved skin
antiseptic just prior to
piercing.
1
Client
preparation
single-use towel
A towel may be used to
drape the piercing site.
2
Skin
preparation
Skin antiseptic,
(e.g. 70% alcohol
or an iodine, such
as betadine). The
antiseptic
selected must be
appropriate for
the piercing site
and must be
used according to
the
manufacturer’s
instructions.
Swabs moistened with
an antiseptic are used
to disinfect the skin
piercing sites.
Clean swabs,
(e.g. gauze or
cotton balls).
3
Jewellery
studs are the
common form
Jewellery used for
piercing must be sterile.
Jewellery must be
smooth to avoid skin
damage, which delays
healing and increases the
risk of infection.
65
4
Ear piercing
instrument
Equipment/
Supplies
Use During Skin
Piercing
Procedures for
Infection Prevention
single-use prepackaged stud
and butterfly
clasp
The stud is pierced
through the lobe of the
ear by the practitioner
through activation of
the spring mechanism
in the instrument or by
squeezing the
instrument. The
butterfly clasp at the
back of the ear lobe
holds the stud in place.
The piercing instrument
is used to hold the
sterile stud. Blood may
be splattered onto the
instrument as the stud
is pierced through ear
tissue.
Studs must be sterile and
pre-packaged.
head of piercing
instrument
a single-use
removable
cartridge is
strongly
recommended.
5
Client
aftercare
soap
alcohol-based
hand rubs
Clients shall be
instructed to perform
hand hygiene before
washing the pierced
area with soap on a
daily basis and to rotate
the jewellery to help
with the cleaning
process.
antibacterial
ointment
Ointment may be
applied to the freshly
pierced skin area and
the jewellery should be
rotated.
The removable cartridge
must be discarded after
single-use. The piercing
instrument surface must
be cleaned then soaked
in an intermediate to high
level disinfectant, (e.g.
70% alcohol) between
clients.
The skin piercing site
shall be cleaned to
promote healing and to
prevent the chance of
infection. Oral and written
instructions for aftercare
shall be provided to the
client.
If ointment is used,
single-use ointment
applications are
recommended in a
manner to prevent
contamination. Ointment
acts as a lubricant and
may reduce the chance of
infection.
If ointment is taken from a
bulk container it must be
removed with a singleuse spatula or tongue
depressor.
66
6
Practitioner
supplies
Equipment/
Supplies
hand washing
soap
Use During Skin
Piercing
Soap is used to remove
microorganisms on the
practitioner’s hands.
alcohol-based
hand rubs
Alcohol-based hand
rubs containing
between 60-90%.
hand lotion
Alcohol can be used to
perform hand hygiene
when hands are not
visibly soiled.
Procedures for
Infection Prevention
Refer to
recommendations in
section 6.1.1.
Lotion is used to keep
the skin in good
condition as frequent
hand washing may dry
out the skin.
single-use gloves
Single-use gloves must
be used as a protective
barrier on hands after
cleaning of the skin with
an antiseptic and
before opening the
package that contains
the sterile jewellery. If
the gloves are
contaminated, they
must be removed, hand
hygiene must be
performed and a new
pair put on.
Single-use gloves must
be worn to reduce the
number of organisms on
the hands and offer some
protection from sharps
injuries.
Gloves must be used to
touch only the objects
needed to do the
procedure.
Hand hygiene must be
performed before gloves
are applied and after
glove removal.
67
Table 8: Preparing Household Bleach as a Disinfectant
Adapted from APIC Guideline for Selection and Use of Disinfectants
The solution must be made fresh daily to preserve strength.
Household Bleach Solution is 5.25% sodium hypochlorite solution (50,000 ppm
available chlorine)
Level required
High-level Disinfection
1:50 dilution of bleach (1
part bleach: 49 parts water)
Intermediate-Level
Disinfection
1:50 dilution of bleach (1
part bleach: 49 parts water)
Low-Level Disinfection
1:500 dilution of bleach (1
part bleach: 499 parts
bleach)
When to be used—see
Table 2 on disinfection
Use on semi-critical items:
items that may accidentally
penetrate skin and /or come
into contact with blood or
body fluids. Also use to
clean surfaces following
contact with blood or body
fluids or where sterilization
is not possible.
Contact time > 20 minutes
Use on semi-critical items:
items that may accidentally
penetrate skin and/or come
into contact with blood or
body fluids (e.g. hair
clippers, cuticle scissors).
How to mix the bleach
solution
10 ml bleach with 495 ml
water
or
2 tsp. bleach with 2 cups
water
10 ml bleach with 495 ml
water
or
2 tsp. bleach with 2 cups
water
Contact time > 10 minutes
Use on non-critical items:
items that come in contact
but do not penetrate intact
skin, or those that do not
ordinarily touch the client.
These items do not contact
blood or body fluids. May
be used for routine
housekeeping (e.g. floors or
surfaces).
5 ml bleach with 2½ litres
water
or
1 tsp bleach with 10 cups
water
Contact time > 10 minutes
68
Table 9: Times and Temperatures required for dry heat sterilization
Times and Temperatures Required for Dry Heat Sterilization
Temperature
Time
171 C (340 F)
60 minutes
160 C(320 F)
120 minutes
149 C (300 F)
150 minutes
141 C (285 F)
180 minutes
121 C (250 F)
12 hours
69
Appendices
Appendix 1 Information about Methyl Methacrylate (MMA)………….…..Page 71
Appendix 2 Information about ear candling………………………………..Page 72
70
Appendix 1: Methyl Methacrylate (MMA)
On May 22, 2003, Health Canada released a health advisory warning against the
use of MMA. The strong adhesive properties of MMA can cause painful tearing
and possible permanent loss of the natural nail, should the artificial nail be
jammed or caught. Allergic reactions to MMA include red skin rashes, contact
dermatitis, itching and/or small oozing blisters in the affected area. MMA may
also cause irritation to the nose and throat, as well as headaches.
For the PSW, there is a risk that ongoing exposure to this substance can cause
irritation to the nose and throat, headaches as well as adverse skin reactions.
Masks worn to reduce exposure to dust are not designed to reduce the effect of
the MMA vapours.
No cosmetic products containing MMA are to be sold in Canada. Ethyl
methacrylate, plymethyl methacrylate and other methacrylate polymers are all
alternatives to MMA which are currently permitted by Health Canada for use in
cosmetic products. However, some cosmetic products containing MMA may still
be available on the Canadian marketplace.
For further information, contact your nearest Health Canada Product Safety
Office:
http://www.hc-sc.gc.ca/home-accueil/contact/hecs-dgsesc/pso-bsp_ncrrcn_e.html
For further information you may also refer to Health Canada’s website at:
http://www.hc-sc.gc.ca/ewh-semt/pubs/contaminants/psl1lsp1/methyl_methacrylate_methyle/methyl_methacrylate_methyle_synopsis_e.ht
ml
71
Appendix 2: Ear Candling
Ear Candling refers to a variety of procedures that are associated with placing a
hollow cone-shaped device in the ear for the supposed purpose of extracting
earwax and other impurities. The cone is soaked in beeswax or paraffin that is
then hardened. During ear candling, the client lies on his/her side while another
person inserts the point of the cone into the ear. The top of the cone is then set
on fire and allowed to burn for a few minutes.
The health claim made for these products is that the flame creates warmth and
suction, to draw earwax out of the ear canal. Since earwax is sticky, significant
negative pressure would be required in order to pull the wax from the ear canal.
Health Canada has conducted laboratory tests that showed that ear candling
produced no significant heating or suction in the ear canal.
There are significant dangers posed by ear candling. It can result in a risk of fire,
and can cause serious burns or other injuries should the hot wax drip into the
ear, skin or hair. A number of cases of ear injury have been reported in Canada.
Ear candles cannot be legally sold in Canada. The Medical Devices Regulations
of Canada’s Food and Drugs Act states that medical devices, such as ear
candles, must be licensed by the Therapeutic Products Program of Health
Canada before this product can be legally sold. No licenses have been granted
for ear candles to be used for therapeutic purposes.
For further information you may also refer to Health Canada’s website at:
http://www.hc-sc.gc.ca/iyh-vsv/med/ear-oreille_e.html
72
Acknowledgements
The assistance of the following individuals in the development and review of the
Infection Prevention and Control Best Practices for Personal Services Settings is
greatly appreciated:
Ms. Cecilia Alterman, Toronto Public Health
Dr. Erika Bontovics, Ministry of Health and Long-Term Care
Ms. Mary-Anne Carson, Halton Region Health Department
Ms. Dorothy Galantai, Region of Waterloo, Public Health
Mr. Peter Heywood, Region of Waterloo, Public Health
Mr. Jim Kalogritsas, Simcoe Muskoka District Health Unit
Mr. Burgess Hawkins, Halton Region Health Department
Ms. Lucie Imbiscuso, Wellington-Dufferin-Guelph Public Health Unit
Mr. Christian Lapensee, Ottawa Public Health
Ms. Penny Lewick, Halton Region Health Department
Mr. Bernie Mayer, Simcoe Muskoka District Health Unit
Ms. Anna Miranda, Toronto Public Health
Ms. Toni Moran, Regional Municipality of Durham Health Department
Ms. Lisa Penney, Toronto Public Health
Ms. Selina Pittman, York Region Health Services
Ms. Danielle Steinman, Regional Municipality of Peel Health Department
Ms. Brenda Stiver, Regional Municipality of Durham Health Department
Ms. Anne-Luise Winter, Ministry of Health and Long-Term Care
73